Blanchard, Terry NEW YORK STATE DEPARTMENT OF HEALTH • Y 431
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Terry Blanchard Female
Date of Death .Age If Veteran of U.S.Armed Forces,
F, August 6, 2018 43 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Whitehall Street Address Home
0 Manner of Death 0 Natural Cause 0 Accident n Homicide (Suicide n Undetermined I I Pending
W Circumstances Investigation
O Medical Certifier Name Title
W Wesley Perry _ Coroner
a Address
26 Mettowee Street Granville New York 12832
Death Certificate Filed District Number 70�g Register Number
City,Town or Village Whitehall
Burial Date Cemetery or Crematory
r—� August 10, 2018 Pineview Crematorium
1 1�1 Entombment Address
[ Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
- and/or Address
1" Hold
0 Date Point of
n Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
on Disinterment
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I— Name of Funeral Firm Making Disposition or to Whom
E Remains are Shipped, If Other than Above
C
W Address
O.
Permission is hereby granted to dispose of the human ains descr' edtabove as indicated.
Date Issued g-1-ob `/��
Ig Registrar of Vital Statistics U+ A/t1.64
p� (signature)
District Number S 1 a O Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z "1
W Date of Disposition 08/+ /2018 Place of Disposition Pineview Crematorium
2 (address)
W
N
Ce
0 0 (section) (lo insse umber) c (grave number)
Name of Sexton or Person in Charge of Pre ises 31.4
W (plea print)
Signature Title ra inti
(over)
DOH-1555 (02/2004)