Blanchard 111, Frederick Leo F ,t1 1
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f-�`11L11L'����',,,,,,4 %` TENNESSEE DEPARTMENT OF HEALTH
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OFFICE OF VITAL RECORDS
PERMIT FOR FINAL DISPOSITION OF HUMAN REMAINS
Name of Decedent Sex Date of Birth Date of Death
Frederick Leo Blanchard Ill Male 1/9/1980 9/19/2021
Place of Death—City or Town, County I Name of Informant
Knoxville/Knox Michelle Blanchard
Name of Funeral Director(or Person Acting as Such) Name of Physician Who Will Certify Death
Larry J. Click Andrews Paul _
Address of Funeral Director(or Person Acting as such)
9020 Middlebrook Pike, Knoxville, TN
I hereby apply fora permit for the disposition of the remains of the above named decedent. I agree to abide
by all laws and rules of the Tennessee Department of Health and all other laws pertaining to the preparation,
container, transportation, and burial of human remains. If I have not been able to submit a certificate of
death for this person at the time of this application, I agree to file, within five days of the date of death, the
APPLICATION properly completed certificate with the local registrar in the county where the death occurred.
FOR PERMIT
_ .D0 q
s.Signature Date igned
9020 iddlebrook Pike, Knoxville, TN 37923
Address
TYPE OF PERMIT REQUESTED -Check all boxes that are applicable
Burial V Transit Scientific Use
Note: This form may NOT be used as a permit for cremation.
Name and Address of Cemetery where Remains are to be Interred.
BURIAL
TRANSIT From. Knoxville, Tennessee To Queensbury, New York
Name and Address of Facility Receiving Remains
SCIENTIFIC USE
This permit for the final disposition of the remains of the person named above is granted for the purpose(s)
checked above.
PERMIT OF ,�( aD c O�
LOCAL OR C-' /
DEPUTY Signature of Lo I or DeP4ty Registrar Date igned
REGISTRAR qj t)__-rt iaekt- "6~°o K "1 KC_-_-.._____
Address
Sp>c&1 ,11- La✓ 3-7 S 3
I certify that the disposition of the remains of the above named was made in accordance with this permit on
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CERTIFICATION Date Place
OF PERSON IN
CHARGE OF THE - _! __ -------
DISPOSITION Sign ure
Address
When the disposition is complete, mail this form to the local or deputy registrar who issued this permit.
PH-3774 RDA 1468
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on - , 20
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Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#