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Blake, Lewis NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Lewis Libby Blake Male Date of Death Age If Veteran of U.S.Armed Forces, 05/10/2022 65 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death I1NaturalCause Accident Homicide Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Matthew Loftus PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 270 ©Burial Date Cemetery,Crematory or Facility Name 05/20/2022 Pine View Cemetery Entombment Address Cremation Queensbury Town,New York EIDonation g El Removal Date Place Removed and/or and/or Held - Hold Address (/) 0 O. Date Point of U)ElTransportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/18/2022 Registrar of Vital Statistics 9ldeganWolin(ECectronicallySigned) (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 5 aya Place of Disposition a I 4U{ � kb 111 v e n4y c C w /address 4RIc ii OD U)CC (section (lot number) (grave number) Name of Sexton or Person in Charge of Premises �nn I <, C.A71 Z p (please print) W Signature I/l�t °L Title Sii per rik khf DOH-1555(o7/18)pi of 2 Public Health Law Sec. 4145(2b) 012917 Receipt Human remains of L delivered on , , 20 I Pine View Cemetery -- Repretenting ffie funeral home named on burial permit Official Funeral Directors Reg.or License# ;, BLAKE NAME Lewis Blake Age: 65 Lot Owner: Lewis Blake Lot# Horicon 20S Grave# 1 Case: Concrete Died: 5.1 0.2 2 Interred:5.2 0.2 2 Funeral Home: Baker FH Cemetery: Pine View