Freebern, James E Sr. III) / Lb
NEW YORK STATE DEPARTMENT OF HEALTH -- ` Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James E Freebem Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/20/2023 78 Years War or Dates 1963-66
F Place of Death Hospital,Institution or
WCity,Town or Village Corinth Town Street Address 642 County Route 24,Corinth Town, New York 12822
p Manner of Death El Natural Cause Accident 0 Homicide Suicide FlUndetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
a Thomas Coppens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Corinth District Number Register Number
City,Town or Village 4553 18
EIBurial Date Cemetery,Crematory or Facility Name
08/22/2023 Pineview Crematory
Entombment Address
®Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
Q and/or and/or Held
F- Hold Address
N
Q. Date Point of
Cl)❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
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
li— Remains are Shipped,If Other than Above
2 Address
CC
W
CI' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/21/2023 Registrar of Vital Statistics Brenda L Penis(Electronically Signed)
(signature)
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition /S(ZZ(7 5 Place of Disposition Pi AL-
2 (address)
W
NCC (sectkm) (/ot umber) (grave number)
� Sit
gName of Sexton or Person in Charge of Premises /p/easeprfvtJ
w / +
Signature Title
DOH-1555(07/18)p 1 of 2
I7
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#