Joubert, Eugene A ' ' ft-CF.) .il6 (it)
NEW YORK STATE DEPARTMENT OF HEALTH �-- Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Eugene A Joubert Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/09/2022 81 Years War or Dates
F— Place of Death Hospital,Institution or
LIJ
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death 0 Natural Cause Accident 0 Homicide []Suicide ElUndetermined ❑Pending
W
U Circumstances Investigation
LU Medical Certifier Name Title
CI
Stephen Perazzelli MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 473
BurialEl
Date Cemetery,Crematory or Facility Name
08/11/2022 Pineview Crematory
Entombment Address
MCremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
d Date Point of
U) ■Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
al Reinterment
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
"t Address
CC
LU
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/10/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
•
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ���
I—
Z U_ L f
Date of Disposition 81 t2 17Z Place of Disposition i ti i
W
(address)
W
U)
CC (section) ._(lot numbeStiv, (grave number)
0 Name of Sexton or Person in Charge of Premis it, a(-
0 lease print)
Z
W rR�fftNRa2
Signature Title
DOH-1555(07/18)p 1 of 2
J
�d
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#