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Goldblatt, Peter J 4156"? NEW YORK STATE DEPARTMENT OF HEALTH - - ' Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Peter J.Goldblatt Male Date of Death Age If Veteran of U.S.Armed Forces, 11/13/2021 88 Years War or Dates 1957-1960 H Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause ❑Accident ❑Homicide E Suicide Undetermined Pending WEi C.) Circumstances Investigation a Medical Certifier Name Title Shahid Ahmed MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 511 LiBurial Date Cemetery,Crematory or Facility Name 11/15/2021 : .' Pine View Crematory ❑Entombment Address lCremation Queensbury Town, New York ❑Donation ZRemoval Date Place Removed H and/or and/or Held N Hold Address 0 4. Date Point of N I=1 Transportation El. Common Shipment Carrier Destination ElDisinterment -flate Cemetery Address Reinterment Date.: Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom i— Remains are Shipped,If Other than Above 2 Address W I 0 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/15/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically 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: I— W Date of Disposition (i ii� ZI Place of Disposition Attie— �.. a. 2 (address) W CC (section) (lot number) r, (grave number) GName of Sexton or Person in Chargj Premises 1 T s' Z (pl f ase print) W Signature Title ��' /►°tlirk DOH-1555(07/18)p 1 of 2 n1 9R 34 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#