Blackmer Sr., David Sterling . . SSi
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vitat Records
Name First Middle Last Sex
David Sterling Blackmer Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/19/2021 55 Years War or Dates
Place of Death Hospital,Institution or
Z City.Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Manner of Death Natural Cause Accident Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
C3 Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 300
O Burial Date Cemetery,Crematory or Facility Name
07/21/2021 Pine View Crematorium
Entombment Address
X❑Cremation Queensbury Town,New York
▪Donation
ZO Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
4 Date Point of
(f) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67, Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H- Remains are Shipped,If Other than Above
5 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/21/2021 Registrar of Vital Statistics &bertAndrew Curtis(ECectronicalTy Signed)
(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 permit on:
IF-
Z Date of Disposition 2 Place of Disposition rj n{; V;L+✓ cr¢4,,;i.irr'l
2 (address)
W
CC
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises J. r r-{.;' SC, A
Z (please print)
W t
Signature )Z�. Title Cyr ys,cric/
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b) 01r 4 9 6 2
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
1