Blackowl, Paul IT- 1 54
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section i . . Burial - Transit Permit
Name First Middle Last Sex
Paul R. Blackowl Male
• Date of Death Age If Veteran of U.S. Armed Forces,
August 4,2011 52 War or Dates No
i1Place of Death Hospital, Institution or
City,Town or Village So. Glens Falls Street Address 86 Feeder Dam Rd
ei Manner of Death Irn
Xi Natural Cause n Accident n Homicide Suicide n Undetermined Pending
US, Circumstances Investigation
' Medical Certifier Name Title
CI David Cunningham Dr.
Address
3 Irongate Center,Glens Falls,NY 12801
:% Death Certificate Filed District Number Register Number
°
. . City, Town or Village Town Of Moreau
,. ❑Burial Date Cemetery or Crematory
❑Entombment August 8, 2011 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ Removal and/or Held
• and/or Address
E Hold
O Date Point of
y n Transportation Shipment
'p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
o:a1 Permit Issued to Registration Number
:.:::1 Name of Funeral Home Regan& Denny Funeral Home 01443
Address
`: 53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
is Remains are Shipped, If Other than Above
iAddress
7i Permission is hereby granted to dispose of the human rema'ns described abov as indicated.
• Date Issued 9-K-a6,I/ Registrar of Vital Statistics c.).1
(signature)
• District Number4454,a. Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition c'-1 o-.t J Place of Disposition Pi tie toil-e, � Lr-cv)/a°t C.'vw1
a (address)
W
co (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises .';6-01i i�n��/�
Z (please print)
W Signature,- Title Cr.e.0,4 r./ Y c'5I-
(over)
DOH-1555(02/2004)