Blackmer, John Elson 123
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle. Last Sex
John Elson Blackmer Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/09/2022 62 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Kingsbury Town Street Address 1028 Dix Avenue Lot 10, Kingsbury Town,New York 12839
C) Manner of Death I^ I Natural Cause Accident []Homicide []Suicide []Undetermined ❑Pending
W '._ ' f 'Circumstances Investigation
W Medical Certifier Name Title
William Parker MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,Town or Village 5762 16
[]Burial Date Cemetery,Crematory or Facility Name
09/12/2022 Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
Donation
o E Removal Date Place Removed
and/or and/or Held
- Hold Address
0
d Date Point of
(1)[]Transportation Shipme it
by Common
Carrier Destination
[]Disinterment
Date Cemetery Address
Date Cemetery Address
[]Reinterment
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
Remains are Shipped,If Other than Above
2 Address
a" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/12/2022 Registrar of Vital Statistics Cyntliia)t Bardin(Electronically Signed)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition q\)Z(2 Place of Disposition
(address)
W
NCC (section) (lot number/ (grave number/
d Name of Sexton or Person in Charge of Pre .ses �C
+ lease print,
W TGle
Signature Title ie, rn�
DOH-1555(07/18)p t of 2
�-,� �y^R 9'q,r
0 _623
Public Health Law Sec. 4145(2b)
Receipt
1
Human remains of delivered on , 20 " 7_
Pine View Cemetery Representing the funeral home named pn burial permit
Official Funeral Directors Reg.or License# I