Blazoski, Edward NEW YORK STATE DEPARTMENT OF HEALTH
I a (1(6
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
[_iciard T. Blazos K° M
Date of Death 0 8/0 9/2 01 2 Age 7 9 If Veteran of U.S. Armed Forces,
War or Dates Korean
laa Place of Death Hospital, Institution or
City, Town or Village City of Glens Fal=Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident 0 Homicide ❑Suicide 0 Undetermined ❑Pending
l Circumstances Investigation
Ili Medical Certifier Name Title
n dde � P w'J
Ieap � 4 r ) )-s/
th Certificate Filed District Nuber Register Number
City; own or Village Glens Falls 56oi 3 -7?
Burial Date � 1 C 2. Cemetery or Crematory Pine View Crematory
0 Entombment
Address
Iiii®Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9 ❑and/or Address
a- Hold
0 Date Point of
it
Q Transportation Shipment
15 by Common Destination
Carrier
Disinterment Date Cemetery Address
Ilili
Q Reinterment Date Cemetery Address
Permit Issued to M.B Kilmer Funeral Home Registration Number
Name of Funeral Home 01079
Address
82 Broadway Fort Edward, STY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above Edward L. Kelly Funeral Home
Address
Z. 1019 US Route 9_ Schroon Lake, NY 12870
Ill
9.!.:1 Permission is hereby granted to dispose of the human remains described above as indicated.
Eiit Date Issued ` q[ j2 Registrar of Vital Statistics CA3 ck, --,q .,&".
/ ,� yy "U' _" (signature)
District Number 5 6 0 I Place 6 l.i'� s FCA ``S,Ny
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 4-0-I2, Place of Disposition .f p...t o cfp.Prt,
(address)
Ili
Le
cC ' (section) (lot number) c (grave number)
ci Name of Sexton or Person in Charge of Premises NI) Jthsit
please print)
uf
Signature Title Ct�cM1 o1
i
(over)
DOH-1555 (02/2004)