Blackburn, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard W. Blackburn Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 2,2013 67 War or Dates Vietnam
Place of Death Hospital, Institution or
t, City, Town or Village Minerva Street Address 1335 County Route 29, Olmstedville
pManner of Death X Natural Cause I 1 Accident Homicide Suicide Undetermined [ Pending
W Circumstances Investigation
Au Medical Certifier Name Title
Daniel Way MD
Address
WHIN,North Creek,NY 12853
Death Certificate Filed District Number Register Number
City, Town or Village Minerva 1557 04
❑Burial Date Cemetery or Crematory
Entombment November 5,2013 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZO I 1 Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N I 1 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ce
rat
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11-5-13 Registrar of Vital Statistics
(signature)
District Number 1557 Place T/O Minerva,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�n
im Date of Disposition II /��13 Place of Disposition '�Inttei4
W (address)
CC
(section) (lot umber) f• (grave number)
pName of Sexton or Person in Charge of Premises ; v OM*(p(cumber)
print)
Signature Title 61)CillINTOC
(over)
DOH-1555 (02/2004)