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Blevins, Mark NEW YORK STATE DEPARTMENT OF HEALTH { . 6O Vital Records Section Burial - Transit Permit Name First Middle Last Sex Mark Stephen Blevins Male Date of Death Age If Veteran of U.S. Armed Forces, October 22, 2014 21 War or Dates F Place of Deat Hospital, Institution or W" City, Town or ills Hudson Falls Street Address 18 School Street Ci Manner of Death❑ Natural Cause 0 Accident 0 Homicide Suicide 0 Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title © Max Crossman, M.D. Dr. Address Whitehall Family Health Whitehall, NY 12887 Death Certificat led District Number Register Number City, Town 01%119.20 ti-UDSOKI rALL, .S 7,2 4 fg ❑Burial Date Cemetery or Crematory October 27, 2014 Pine View Crematorium ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 4 Removal and/or Held O and/or Address _ Hold CO Date Point of p,, El Transportation Shipment (I) by Common Destination 3 Carrier 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom h Remains are Shipped, If Other than Above 2` Address U C Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued /0 `.j 7 - /y Registrar of Vital Statistics . a •%3.„4 / ' (signature) District Number 5 ') 3 6 Place U r //G (.� G f / t�s0 n �G /1 s I certify that the remains of the decedent identified abovewere disposed of in accordance with this permit on: W Date of Disposition 10/27/2014 Place of Disposition Quaker Road Queensbury,NY 12804 W (address) CO (section) /� (lot number)) (grave number) p Name of Sexton or Person in Charge of Premises 4,.%- -cciKa z / ( lease print) W' Signature (6 mod-- Title C14 0'FIK (over) DOH-1555 (02/2004)