Campbell, Jane A. NEW YORKSTATE DEPARTMENT OF HEALTH ?` z-
Bureau of Vital Records - . Burial - Transit Permit
Name First Middle Last Sex
Jane A.Campbell I Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/08/2020 86 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803
WManner of Death Natural Cause Accident Homicide Suicide ❑Undetermined Pending
V
Circumstances Investigation
WG Medical Certifier Name Title
Thomas Coppens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate filed District Number Register Number
City,Town or Village Moreau 4562 13
Burial Date Cemetery,Crematory or Facility Name
❑
03/10/2020 Pine View Crematory Entombment Address
Cremation Queensbury Town,New York
Donation
ORemoval Date Place Removed
and/or and/or Held
Hold Address
fl
d Transportation Date Point of
by Common Shipment
Carrier Destination
FIDisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/10/2020 Registrar of Vital Statistics LeeannMcca6e(ElectmnicwySrgned)
/signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H JI �
W Date of Disposition 311� 1,0 Place of Disposition Z(Le-'t-d tug....
Uj (address)
W
Ir (section) (tot number) /grave number)
Name of Sexton or Person in Charge of remises n► It�--
Z (pie se print)
W Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013408
Receipt
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#