Hamblin, Jeffery B., Jr. •
2l
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeffery B Hamblin Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/22/2022 31 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Saratoga Springs Street Address Saratoga Hospital
• Manner of Death El Natural Cause 0 Accident ❑Homicide El Suicide ❑Undetermined ❑X Pending
Circumstances Investigation
W Medical Certifier Name Title
O Susan Hayes-Masa Coroner
Address
40 McMaster Street,Ballston Spa Village,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 54
ElBurial Date Cemetery,Crematory or Facility Name
01/24/2022 Pineview Crematory
Entombment Address
ElCremation Queensbury Town,New York
ElDonation
ZO❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
Cl) ❑Transportation
by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
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
E.. Remains are Shipped,If Other than Above
. Address
W
FL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/24/2022 Registrar of Vital Statistics rDi'mt Moran(Elecrnmtca1'Stgned)
(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:
F—
W Date of Disposition / )A4133_2_ Place of Disposition vie„,
(address)
IW
N (section) (lot number) (grave number)
8 Name of Sexton or Per n in Charge of Premises c.)A/Cr% -5€iAr,S
Z (please print)
UJ Cirt,r,k10 r
Signature Title
DOH-1555(07/ )p i of 2
5 5 7 8
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# --