Champion, Laurie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - r nsit Permit
rg Name First Middle Last Sex
Laurie J. • Champion Female
';'0 Date of Death Age If Veteran of U.S. Armed Forces,
;fir,
June 5, 2016 55 War or Dates n/a
l Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death j Natural Cause ❑Accident n Homicide _Suicide Undetermined n Pending
Circumstances Investigation
- Medical Certifier Name Title
1Dr Stoutenberg,MD
OS
Address
01 Glens Falls,NY
�,;; Death Certificate Filed District Number Register Number
r/ City, Town or Village Glens Falls, NY 5601 r ?.5"
❑Burial Date Cemetery or Crematory
❑Entombment June 8,2016 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
Hold
O Date Point of
03 Ti Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
,r%. Name of Funeral Firm Making Disposition or to Whom
1'= Remains are Shipped, If Other than Above
Address
f Permission is hereby granted to dispose of the human rei ains d scribed bove as i _ -d.
rf;
- Date Issued 1 R:::t
rar of Vital Statistic Ai.ae.
%v sign ure)
fy, District Number0 r„/A
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I certify that the remains of the decedent identified above were disposed ofin accordance with his permit on:
itt Date of Disposition 4 1 (o la, Place of Disposition Rita,/
(a dress)
W
CA
CC (section) // (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises /4rtf L
Z
W aSignature Title GrPi
(over)
DOH-1555(02/2004)