Bleickhardt, Alex William LF-%\ 3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records _R -
Name First Middle Last Sex
Alex William Bleickhardt Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/15/2022 33 Years War or Dates
1.,.. Place of Death Hospital,Institution or
Z City,Town or Village Wilton Town Street Address 33.9 Mile S Interstate 87,Wilton Town,New York 12831
O Manner of Death Ej Natural Cause Accident Li Homicide Suicide ❑Undetermined ❑Pending
LU
0 Circumstances Investigation
W Medical Certifier Name Title
O David DeCelle Coroner
Address
40 McMaster Street„ Ilston Spa,New York 12020
Death Certificate Filed town Of Wilton District Number Register Number
City,Town or Village 4569 53
ElBurial Date Cemetery,Crematory or Facility Name
09/19/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Date Place Removed I j:
• and ov f and/or Held
H and/or'
CDHold;, Address
0
I.. Date Point of
CO❑Transportation
b by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
f.. Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/19/2022 Registrar of Vital Statistics Susan Baftwin(EhctronicaITySigned)
(signature)
District Number 4569 Place Town Of Wilton
to
416
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition CM'U, Place of Disposition 4/.
2 (address)
W
U) (section) /� (lot number) (grave number)
S� GGG/,L,1
Name of Sexton or Person in Cha Premises r,,'L -Av
/p se print)
Z / �� a
IU Signature Title
DOH-1555(07/18)p 1 of 2
1 RF 4
Public Health Law Sec. 4145(2b) • -
Receipt
Human remains of !` delivered on , 20�
Pine View Cemetery Representing the funeral home named pnburial.permit
Official Funeral Directors Reg.or License# -