Blair, joseph Effill f qf)
NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Joseph Effill Blair Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/22/2020 87 Years War or Dates NationalGuard
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 763 Bay Road,Queensbury Town,New York 12804
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p Manner of Death 91 Natural Cause Accident Homicide Suicide Undetermined Pending
u� Circumstances Investigation
U
W Medical Certifier Name Title
0 Joseph Mihindukulasuriya MD
Address
20 Murray Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town orVilt a Queensbury 5657 80
Burial Date Cemetery,Crematory or Facility Name
04/27/2020 Pine View Crematory
Entombment Address
nCremation Queensbury Town,New York
❑Donation
O ❑Removal Date Place Removed
and/or and/or Held
N
Hold Address
O
G. Date Point of
N ❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
Address
W
I" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/27/2020 Registrar of Vital Statistics CarolrneXrl�egar�Bar6er(Electronrca�Sagne�
(signature/
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F— rJ
Z Date of Disposition 'I 128(10 Place of Disposition `t%—
LU (address)
Z
W
N (section) (!oIn amber) (grave number)
Q
Name of Sexton or Person in Charge of Premises f'
z lease print/
W Signature Title
DOH-1555(07/18)p 1of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20_
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#