Blanchard, Charles tt653
NEW YORK STATE DEPARTMENT OF HEALTIi: #
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles E. Blanchard Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 7, 201 5 76 yrs. War or Dates No
Place of Death Town of Hospital, Institution or 697 Hog Back Road
tu City, Town or Village Crown Point Street Address
0 Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
tt Circumstances Investigation
isi Medical Certifier Name Title
0 Glen Chapman a M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Crown Point ' 1 551 6
['Burial Date metery or Crematory
09/10/2015 Pine View Crematory
gii ❑Entombment Address
iii®Cremation Queensbury, New York
Date Place Removed '
Z❑Removal and/or Held
2 and/or Address
t Hold
CO
0 Date Point of
CL
❑Transportation 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
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
lit
,. Permission is hereby granted to dispose of the human rem ' desc r • abo -- as dica
Date Issued 09/09/201 5 Registrar of Vital Sta . cs —
�'signa ure)
District Number jss' Place Town of Croltin Point
--(1 .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LU Date of Disposition 1,41 Ii6" Place of Disposition ;emu..., C, ar,,.,r
(address)
Iii
CA
fr (section) � (lot number)`- (grave number)
Ci Name of Sexton or Person in Charge of Premises 1 L 7r+,J J er,t049-
et
z ( ease print)
La
Signature4 Title arycli j7iL
(over)
DOH-1555 (02/2004)