Hamblin, Brian NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section {� - Burial - Transit Permit
Name First Middle Last Sex
Brian Joseph Hamblin Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 28, 2018 66 War or Dates
wPlace of Death Hospital, Institution or
F City, Town or Village Street Address 14 Walnut Street
W Manner of Death Lu Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
FW: Medical Certifier Name Title
Darci Gaiotti-Grubbs, Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed I District Number Register Number
City, Town or Village S']9,to 3 o
❑Burial Date Cemetery or Crematory
December 31, 2018 I Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
•,❑ Removal and/or Held
and/or Address
H Hold Pine View Crematorium
00).4. Date Point of
❑Transportation Shipment
by Common Destination
;C Carrier
3 0 Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
,, Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
14- Remains are Shipped, If Other than Above
M= Address
'
LW
Fi Permission is hereby granted to dispose of the human re ains escribed above as indicated.
11- Date Issued 1 -a.- a,o i9 Registrar of Vital Statistics � C���
(signature)
District Number 7 L Place .��
�c . y.) t
I certify that the remains of the decedent identified aboveO
` were disposed of in accordance with this permit on:
W
uj Date of Disposition 12/31/2018 Place of Disposition Quaker Road Queensbury,NY 12804
2., (address)
L-f3.
a (section) l (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises4 �'`4�l �r'"�((t
(please print)
Signature L— Title ((Lev jr-
--,
(over)DOH-1555 (02/2004)