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Blakely Sr., Stephen 10 e NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit Name First Middle Last Sex Stephen D.Blakely Sr. Male Date of Death Age If Veteran of U.S. Armed Forces, 01/16/2018 67 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide 0 Suicide ❑ Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Suzanne Rayeski DO Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 29 El Burial Date Cemetery or Crematory 01/18/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed El Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/18/2018 Registrar of Vital Statistics WcdertA Curtis(ECectronica1TySigned) (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: Date of Disposition 1 /zz I l8 Place of Disposition {� �� / o-.../ (address) (section) „7 (lot number (grave number) Name of Sexton or Person in Charge o Premises 4erL n (please print) Signature Title (R6Mn ibe— (over) DOH-1555 (02/2004)