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Blake, Michael T NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael T Blake Male Date of Death Age If Veteran of U.S.Armed Forces, 05/13/2023 43 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Lake Luzeme Town Street Address 384 Lake Avenue,Lake Luzeme Town,New York 12846 p Manner of Death Natural Cause Accident EI Homicide ESuicide Undetermined ❑Pending W Circumstances Investigation 11,1 Medical Certifier Name Title Paul Bachman MD Address 9 Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed Town Of Lake Luzeme District Number Register Number City,Town or Village 5656 4 Burial Date Cemetery,Crematory or Facility Name 05/16/2023 Pineview Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 0. Date Point of to❑Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom 1-. Remains are Shipped,If Other than Above a Address 2 W 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/15/2023 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed) (signature) District Number 5656 Place Town Of Lake Luzeme I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F— Z Date of Disposition S=jG-z'Z 3 Place of Disposition 9 , ,Je r�z) 1 �4 r� , i d'. 2 (address) W CO (section) otn(tuber) (grave number) 8 Name of Sexton or Person in Charge of P ises A//nd�i) Ak W ��� (please print) Signature Title Cerf-X- DOH-1555(07/18)pi of 2 j C3 ` e 40 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#