Blackmer, June NEW YORK STATE DEPARTMENT OF HEALTH \ Burial - Transit 13ermit
Vital Records Section
Name First Middle Last Sex
_ June Rose Blackmer 1 Female
Date of Death Age I If Veteran of U.S. Armed Forces,
February 2, 2011 79 War or Dates _
t... Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death I X Natural Cause Accident I I Homicide Suicide Undetermined Pending
W Circumstances Investigation
,Lu Medical Certifier Name Title
Rachid Daoui,MD Dr.
Address
1 West Medical, Suite 305, Saratoga Springs,NY 12866
Death Certificate Filed I District Number I Register Number
City, Town or Village Glens Falls,NY 5601 I 51
❑Burial Date I Cemetery or Crematory
February 7, 2011 Pine View Crematorium
Entombment Address
EI Cremation 21 Quaker Road, Queensbury, NY 12804 _
Date ! Place Removed
Z Removal and/or Held
and/or Address
,l— Hold
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O Date Point of
NTransportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home Sullivan Minahan & Potter 01675
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
re
W —
O. Permission is h reb granted to dispose of the human r:mains d-scribed abq�ie as indic• ed.
Date Issue Registrar of Vital Statistics // _�\ /� A -
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4-0 11264 Place of Disposition vlt 0 60-cttiro"—
2 t (address)
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ce (section) ,. (lot ember) (grave number)
O Name of Sexton or Person in Charge of remises (L r., qL . ..tti--
Z (please print)
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Signature Title rael tt(6SL
(over)
DOH-1555(02/2004)