Hebert, Cleon C # (/ (i g
e ;
NEW YORK STATE DEPARTMENT OF H EALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Cleon C. Hebert Male -
Date of Death Age If Veteran of U.S.Armed Forces,
08/09/2022 34 Years War or Dates x .,
F.. Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
Q Manner of Death El Natural Cause Accident Homicide Suicide []Undetermined Pending
in
W ' (Circumstances Investigation
WQ Medical Certifier Name • Title
Susan Hayes-Masa Coroner
Address
40 McMaster Street,Ballston Spa Village, New York 1t2020
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village • 4501 475
Burial Date Cemetery,Crematory or Facility Name
08/11/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
to •
0
IL Date Point of
U)[]Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
M Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/11/2022 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:
Ir
Z Date of Disposition /3 p?Z Place of Disposition T►TA] u6g.,to �`r j�ip/�
W (address)
M
W
N (section) (l t number) (grave number)
Q ,,,, ll
Name of Sexton or Person in Char of Pre sesN7i31ll�iV� O/��
Z / L (please print)
W Signature d Tile (�®�-4 45
DOH-1555(o7/18)pi of 2
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#