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Blackmer, Timothy NEW YORK STATE DEPARTMENT OF HEALTH f be % Vital Records Section Burial - Transit Permit Name First Middle Last Sex Timothy M. Blackmer Male Date of Death Age If Veteran of U.S. Armed Forces, April 16, 2018 41 War or Dates ; Place of Death Hospital, Institution or . City, Town or Village Hudson Falls Street Address 47 John Street Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Patricia Auer, Address 316 Carey Road Queensbury, NY 12804 - , Death Certificate Filed District Number Register Number �z- City, Town or Village Hudson Falls .c 7 Ito P ❑Burial Date Cemetery or Crematory April 17, 2018 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold Date Point of ElTransportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number ` Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address vv Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued YJ/ / /f Registrar of Vital Statistics (;%._t, a (signature) District Number 5 7 aG Place tjt//s fc i T Ale, lire#1 - //S certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ut Date of Disposition 04/17/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) iliz (section) /� (lot numbe - (grave number) Name of Sexton or Person in Charge of Premises / Ji. i4 �i ( lease print) Signature Gil Title '�. (over) DOH-1555 (02/2004)