Blake, Stanley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stanley Blake Male
Date of Death Age If Veteran of U.S. Armed Forces,
gn March 12, 2012 52 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 196 Ridge Street
c Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
u Medical Certifier Name Title
j Tim Murphy,Coroner
Address
:: Glens Falls,NY 12801
: Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 72/
❑Burial Date Cemetery or Crematory
El Entombment I'X C 0 2-0 a` Pine View Crematory
Address
❑X Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z 0 Removal and/or Held
and/or Address
H Hold
i5
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I
°s Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
:i Name of Funeral Firm Making Disposition or to Whom
14' Remains are Shipped, If Other than Above
N� Address
til
Permission is hereby granted to dispose of the human remains descr' ed aboovDv as ' i ated.
__° Date Issued 03/4"JO/2-- Registrar of Vital Statistics 41
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition -,;)a-Ih2Place of Disposition telp 0t"pw C.1 m'-,w v
W (address)
co
O (secrio� �i �r ��p�ot number) (grave number)
p Name of Sexton or Person in Charge of emises I ei h
W �� (please print)
Signature �j,��,y ( '444 ' Title Cr•ema 14-1.
(over)
DOH-1555(02/2004)