Bleibtrey, Donald Joseph •
tj. 2. (1/
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald Joseph Bleibtrey Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/23/2020 77 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ❑X Natural Cause ❑Accident ❑Homicide D Suicide El Undetermined El Pending
U Circumstances Investigation
W Medical Certifier Name Title
G Robert Love MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 531
❑Burial Date Cemetery,Crematory or Facility Name
11/25/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
- Hold Address
0
d Date Point of
(/) Li Transportation
Q by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
Cr
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/24/2020 Registrar of Vital Statistics &6ert.,VVndrewCurtis(Electronicall:ySrgner)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this ton:
H (�
Z Date of Disposition 1I 20 Place of Disposition 1
2 (address)
W
CC (section) (lnumber) (grave number)
Name of Sexton or Person in Charge o remises 1'h t''il�
(please p ill_,
W Signature ' Title
/i �� �
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b) 014.2 3 d
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#