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Campney, Barry NEW YORK STATE DEPARTMENT OF HEAL r: 1' 43 Vital Records Section Burial - Transit Permit Name First Middle Last Sex ,`` Barry Francis Campney Male i Date of Death Age If Veteran of U.S. Armed Forces, r January 21, 2011 57 War or Dates Place of Death Hospital, Institution or ,, 3 City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause n Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Anthony Petracca MD, ' Address ,444 Three Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Number ,r� i� ` RegisterNumber City, Town or Village J(Ol I 7 0 Burial Date Cemetery or Crematory January 26, 2011 Pine View Crematorium '. ❑Entombment Address " ©Cremation Quaker Road Queensbury,NY 12804 47 . Date Place Removed ❑ Removal and/or Held and/or Address Hold Pine View Crematorium Date Point of a ❑Transportation Shipment by Common Destination • Carrier ❑ Disinterment Date Cemetery Address Reinterment Date Cemetery Address • -°: Permit Issued to Registration Number 1 Name of Funeral Home Carleton Funeral Home, Inc. 00276 Address 14 Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom x Remains are Shipped, If Other than Above - x Address • Permission is hereby granted to dispose of the human remains descrijbeovo as i cate`. —' Date Issued ©s��Oa/ Registrar of Vital Statistics ' ..,L . (signature) District Number �(eO/ Place 7 _A, /vy I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 01/26/2011 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) (grave number) Name of Sexton or Per n in Charge Premises atTsoko._ Si hqti (please print) Signature - (please O 9 � Title (over) DOH-1555 (02/2004)