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Humphrey, David , 141- 7 Lip NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vitat Records Name First Middle Last Sex David Humphrey Male Date of Death Age If Veteran of U.S.Armed Forces, 03/09/2021 65 Years War or Dates 1— Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address 37 Allen Drive C,Saratoga Springs,New York 12866 Ill Manner of Death © n n Natural Cause Accident Homicide Suicide 0 Undetermined El Pending W Circumstances Investigation U LU Medical Certifier Name Title CI David DeCelle Coroner Address 6012 County Farm Road 1192,Ballston Spa Village,New York 12020 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 198 LiBurial Date Cemetery,Crematory or Facility Name 03/11/2021 Pine View Crematory nEntombment Address 0 Cremation Queensbury Town, New York nDonation Z 0 Removal Date Place Removed and/or and/or Held F— Hold Address N 0 • a Date Point of N n Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address n Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Compassionate Funeral Care Inc 00364 Address 402 Maple Ave,Saratoga Springs,New York 12866 __ Name of Funeral Firm Making Disposition or to Whom f- Remains are Shipped,If Other than Above 5 Address CC LU 0— Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/11/2021 Registrar of Vital Statistics John Pau(Ranck,(rECectronicarrySigned) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit /on: I- 3/-3 Z Date of Disposition fit. t j Place of Disposition ' ;JCS� ili 67,0 CreK s'Ta p 2 (addre W CCCC (section) � (lot number) (grave number/ 0 Name of Sexton or Person in Char e of Premise ice_____,_ �' 1�'� — Z ` /�e (please print) LU Signature Imo° !� 7 r Title Qre.�"t-4A-- DOH-1555(07/18)p t of 2 \4 Public Health Law Sec. 4145(2b) 0 3 4 6 3 4 Receipt Human remains of , delivered on f i . ' , 20 • f i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# - - 1