Blackmer, Roy NEW YORK STATE DEPARTMENT OF HEALTH -{'` 4?
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roy Edwin Blackmer Male
Date of Death ' Age I If Veteran of U.S. Armed Forces,
February 9, 2012 90 War or Dates WWII
F- Place of Death Hospital, Institution or
Z City, Town or Village Argyle Street Address 16 Allen Road
pManner of Death IT1 Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name -- Title
�I A titer M - 6 Ak_I%1, (50(Lao e.L,
Address
11 E&T . oictbtay , SftLem v)y (e. 6s-
Death Certificate Filed District Number Register Number
City, Town or Village Argyle
❑Burial Date Cemetery or Crematory
February 13, 2012 _ Pine View Crematorium
❑Entombment Address
❑x Cremation 21Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
E Hold
N
O Date Point of
c0 Transportation j Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i
Permit Issued to Registration Number
Name of Funeral Home Sullivan-Minahan& Potter 01646
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
E Address
Permission is ereby granted to dispose of the human r ains describe above as indicated.
Date Issued 0 Registrar of Vital Statistics Crill _____"
(signature)
District Number 5�l v Place Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition }c6 (3s ZUt7 Place of Disposition Pi,sa,.... l !we elor.w-
W (address)
Co
CL
(section) (tot number) -- (grave number)
pName of Sexton or P son in Char of Premises Iitrt,� Jto*
Z ( ease print)
W
Signature Title C 6,y
(over)
DOH-1555(02/2004)