Joubert, ArleneNEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last
Sex
I
Arlene M Joubert
Female
Date of Death
Age
If Veteran of U.S. Armed Forces,
09/12/2019
80 Years
War or Dates
p..
Place of Death
Hospital, Institution or
Z
City, Town or Village Ticonderoga Town
Street Address Heritage Commons Residential Health Care
W
0
Manner of Death
❑X Natural Cause Accident Homicide E] Suicide E] Undetermined E] Pending
W
Circumstances Investigation
W
Medical Certifier Name Title
G
Glen Chapman MD
Address
1019 Wicker St, Ticonderoga Town, New York 12883
Death Certificate Filed
District Number
Register Number
City, Town or Village Ticonderoga
1564
59
Burial
Date
Cemetery, Crematory or Facility Name
09/16/2019
Pineview Crematory
Entombment
Address
MCremation
Queensbury Town, New York
ElDonation
ZO
Date
Place Removed
❑Removal
and/or
and/or Held
H
Hold
Address
N
O
(.
Date
Point of
U)
p
Transportation
by Common
Shipment
Carrier
Destination
Disinterment
Date
Cemetery Address
10 Reinterment
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
F—
Remains are Shipped, If Other than Above
Address
W
n'
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/13/2019 Registrar of Vital Statistics Tonya M Thompson (Electronically Signed)
/signature)
District Number 1564 Place Ticonderoga, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition qj1l6j1j Placeof Disposition �:174v. ,y findVfIt-�
W
a
(address)
W
N
(section) (lot number) (grave number)
93
Name of Sexton or Person in Charge of Premises r'� !r""pf
(p ase print)
W
Signature Title l
DOH-1555 (o7/18) p 1 of 2
Y
Public Health Law Sec. 4145(2b)
012533
Receipt
n (`cn���`@ram
Human remains of � 1 delivered on Sr,�� 20
Pine View Cemetery epresenting the funeral home named on burial permit
Official Funeral Directors Reg. or License # / ' `'' ' '