Champagne, Donna NEW YORK STATE DEPARTMENT OF HEALTH
if /51
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donna M. Champagne Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/21/2015 59 years , War or Dates
} Place of Death Hospital, Institution or
City, To Samoa S rings Street Address Sarat°�a—yHospital
Manner of Death Natural Cause Li Accident Homicide-El Suicide LJ Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
L Derek Smith M D
Address
Death Certificate Filed District Number Register Number
' City, ToAvAixx X Saratoga Springs 4501 119
El Burial Date Cemetery or Crematory
❑Entombment 02/24/2016 Pineview Crematory
Address
[,Cremation Queensbury, N Y
Date Place Removed
Removal and/or Held
::.: and/or Address
F_ Hold
VI
O Date Point of
p'El Transportation Shipment
d by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
;l
w
14` Permission is hereby granted to dispose of the human remains ibex! abov as i dicated.
Date Issued 02/24/2016 Registrar of Vital Statistics .—,.,..,„ 0,..k„,, 11
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition Z I7411 Place of Disposition ,eat raJ Ch++vforsu,
2 (address)
W
CO (section) l (lot number) (grave number)
p Name of Sexton or Person in Charge f Premises h+'ipa(W se print)Sa4rl�
(pl
Signature Title ► -
(over)
DOH-1555 (02/2004)