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Crandell, Mills Blackburn It 2LJ NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit I Bureau of Vital.Records Name First Midd�e Last Sex Mills Blackburn Crandell Male Date of Death Age If Veteran of U.S.Armed Forces, 03/04/2021 98 Years War or Dates 1942-1945 Place of Death Hospital,Institution or City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing QManner of Death © Natural Cause El Accident El Homicide 0 Suicide El Undetermined 0 Pending Ili Circumstances Investigation ILI 0 Medical Certifier Name Title Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 28 Burial Date Cemetery,Crematory or Facility Name 03/05/2021 Pineview Crematorium Entombment Address 0 Cremation Queensbury Town,New York ❑Donation oz❑Removal Date Place Removed - and/or and/or Held - Hold Address tin O. Date Point of 0❑Transportation Shipment 5 by Common Carrier Destination ❑Disinterment Date Cemetery Address Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom f•• Remains are Shipped,If Other than Above 5' Address 1 W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/05/2021 Registrar of Vital Statistics Jenny Linda M Martelle(Electronically Signed) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 3 Jf hi Place of Disposition eg4.lb,.� 15-Oc� a (address) W W (section) (lot number)n C_ { (grave number) Name of Sexton or Person in Char of Premises y� (plea print) � Signature Title iii!C K i i*y DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) 0 1 4 E 12 Receipt Human remains of • delivered on , 20 Pine View Cemetery Representing the funeral home named op burial permit Official Funeral Directors Reg.or License#