Black, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
>;< Name First Middle Last Sex
Jeffrey S. Black NA
Date of Death Age ' If Veteran of U.S. Armed Forces,
04 / 25 / 2018 59 War or Dates N/A
Place of Death Hospital, Institution or
City, Town or Village Milton Street Address 6 Linden Lane
Ma
g Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide -1 Undetermined ri Pending
Circumstances Investigation
la Medical Certifier Name Title
A Madhavi Kambam MD
Address
43 New Scotland Ave, Albany, NY 12208
'[` Death Certificate Filed District Number ' i i Register Numbers F '
City,Town or Village Milton '"'1' 1 c )�1
'`> Burial Date Cemetery or Crematory 111
04 / 27 / 2018 Pine View Crematory
iin DEntombment Address
Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
3''" Hold
Date Point of
Q Transportation Shipment
C by Common Destination
iM Carrier
[�Disinterment Date Cemetery Address
ge,[�Reinterment Date Cemetery Address
`> Permit Issued to Registration Number
Mii Name of Funeral Home Compassionate Funeral Care 00364
«< Address
402 Maple Ave., Saratoga Sp., NY 12866
'.<> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above ,
Address
11
iti
44 Permission is ereby granted to dispose of the human r ins descrjbe4above as in ' ated.
Date Issued 4 d Registrar of Vital Statists qS,.dF `
(signature)
i.1 District Number 617( Place Milton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2t;'.,.:
is Date of Disposition S/1 /3 Place of Disposition i�i,,�t..L �j1,,dlfk._
(address)
ILI
CO
CC (section) Ji(lot number) (grave number)
0 Name of Sexton or Person ip Charge of Premises . �+ . 84-14
// (p ase print) •
Signature �✓� � Title t »>�
(over)
DOH-1555 (02/2004)