Champagne, Robert Paul NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert Paul Champagne Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/17/2020 76 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
W Manner of Death Undetermined Pending
a Natural Cause ❑Accident ❑ Homicide ❑Suicide
W Circumstances Investigation
U
W Medical Certifier Name Title
0 Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 175
Burial Date Cemetery,Crematory or Facility Name
03/19/2020 Pine View Crematory
Entombment Address
RI Cremation Queensbury,New York
Donation
Z Removal Date Place Removed
0 and/or and/or Held
H N Hold Address
O
G. Date Point of
N Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
JE]Reinterment--�Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition orto Whom
Remains are Shipped,If Otherthan Above
Address
I2
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/19/2020 Registrar of Vital Statistics Jolrn Paul'Tranck(ELectroni;w1ySigned)
(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:
~ Paw c4)
Z Date of Disposition -Z�-202p Place of Disposition
Uj (a Tess)
W
N (section) (lotnumber) /grave number/
W
Name of Sexton or Pers i arge Prem' es L. �✓t C-ae
/please print/
uJ Signature Title i2i alw�4e�
DOH-1555(07/18)p tof 2
Public Health Law Sec. 4145(2b) 1%'Q,4 41
Receipt
Human remains of r``, i- ` -'� delivered on , 20
`;' s
Pine View Cemetery Representi4 the funeral home named on burial permit
Official Funeral Directors Reg.or License#