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Blackbird, Gerald Sr.
0 N EW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Gerald Raymond Blackbird Male Date of Death Age If Veteran of U.S. Armed Forces, 10/12/2019 74 Years War or Dates Army Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 14 Staple Street, Glens Falls, New York 12801 Manner of Death ©Natural Cause Accident 1:1Homicide Suicide ❑ Undetermined ❑ Pending W Circumstances Investigation Medical Certifier Name Title Thomas Coppens MD Address 100 Park St, Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 446 Burial Date Cemetery, Crematory or Facility Name Entombment 10/16/2019 Pine View Crematorium Address IX 1 Cremation Queensbury, New York Donation Z Date Place Removed O Removal and/or and/or Held �- Hold Address N O IL Date Point of W p Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd, Queensbury, New York 12804 Name of Funeral Firm Making Disposition orto Whom Remains are Shipped, If Other than Above _ Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/15/2019 Registrar of Vital Statistics PpbertAndrew Curtis (Electronically Signet!) (signature/ District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Place Disposition Lt+• e ��- Date of Disposition )o)lb 115 of .� (address/ I11J U) (section) (lotnumber) (grave number) 4A"vpL 8 Name of Sexton or Person in Charge of Premises lease print) W Signature C _Title (Ri DOH-1555 (o7/18) p 1 of 2 Public Health Law Sec. 4145(2b) 0 P 0 2 Receipt Human remains of t `` delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License # "