Blair Sr., Keith Andrew NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Keith Andrew Blair Sr. Male
Date of Death Age If Veteran of U.S:Armed Forces,
12/04/2022 66 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death ❑X NaturaL Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
William Cleaver _ - MID
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 602
Burial Date Cemetery,Crematory or Facility Name
12/06/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
ElRemoval Date Place Removed
and/or and/or Held
f- Hold Address
N
O
a D
(A❑Transportationate Point of
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
II.— Remains are Shipped,If Otherthan Above
Address
cc
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/05/2022 Registrar of Vital Statistics ,Megan NoCzn(ECectronicaCCySigned)
/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:
H
Z Date of Disposition ZZ Place of Disposition
W
g A--
(a
W
Cl)
Q (ssedion) (tot number) (grave number)
0 Name of Sexton or Person in Charge of Pre ' es Swedr-
z (,dffipse print)
W Signature Title
DOH-1555(07/18)p 1 of 2
01646,41
Public Healthtaw Sec. 4145(2b)
Receipt
Human remains of � '"'''' delivered on ��f , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# //61 2 2