Blanchard, James NEW YORK STATE DEPARTMENT OF HEALTH /' 355
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James George Blanchard Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/07/2016 79 yrs. War or Dates 1956-1959
1 Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 276 NYS Rte. 22
C Manner of Death B'Natural Cause ElAccident ❑Homicide 0 Suicide ri❑Undetermined ❑Pending
Ili Circumstances Investigation
W Medical Certifier Name Title
Q Peter Sayers M.D.
Address
17 Miller Drive, Crown Point, NY 12928
Death Certificate Filed Town of District Number Register Number
City, Towri or Village Ticonderoga 1564 25
❑Burial Date Cemetery or Crematory
❑Entombment 05/10/2016 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
9-❑Removal and/or Held
and/or Address
I= Hold
In
0 Date Point of
Q Transportationin El Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
Ei 11 Algonkin St. , Ticonderoga, New York 12883
11 Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
Address
Ii
LEI
` Permission is hereby granted to dispose of the human r n described ove indicated.
» Date Issued 5/1 0/2 01 6 Registrar of Vital Statistics t./1 at ry),./'y h-N--
nature)
District Number 1 564 Place Town of T conderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ilu Date of Disposition c f ii/rt, Place of Disposition ?nt 01tJ t d"riv
(address)
flu
0
CC (section) lot number (grave number
0 Name of Sexton or Person in Charge of remises �M
Z (pl se print)
til
Al Signature Title � � •
(over)
DOH-1555 (02/2004)