Campney, Eleanor NEW YORK STATE DEPARTMENT OF HEALTH : . , i;171'
Vital Records Section Burial - Trasit ermit
Name First Middle Last Sex
Eleanor C. Campney Female
Date of Death Age If Veteran of U.S. Armed Forces,
Feb. 17, 2016 92 yrs. War or Dates no
F4 Place of Death Hospital, Institution or
XCity, Town or Village Fort Ann Street Address 12 Campney Lane
a Manner of Death❑Natural Cause a Accident El Homicide 0 Suicide ElUndetermined ri Pending
Circumstances Investigation
ILI Medical Certifier Name Title
Michael Sikirica MD.
Address
50 Broad St_ , Waterford, NY. 12188
Death Certificate Filed District Number Registar Number
City, Town or Village Fort Ann 5754 1
❑Burial Date Cemetery or Crematory
;>❑Entombment Feb. 19, 2016 PineView Crematorium
Address
i, ®Cremation Oueenshury, NY.
Date Place Removed
❑Removal and/or Held
.., and/or Address
L` Hold
0 Date Point of
fiLi Q Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
s Name of Funeral Home Mason Funeral Home 01117
Address
18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
iii.. Remains are Shipped, If Other than Above
2 Address
cr
til
L Permission is hereby granted to dispose of the human rem described abo r,,' nth ated.
Date Issued 2/1 9/1 6 Registrar of Vital Statistics , j,r �/ ,4, .L�1 //
/.'ign=-ure)
District Number 5754 Place Town of Fort Ann, Y.
1-'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ill Date of Disposition Z doh(, Place of Disposition , litii ( *scltor u„
(address)
111
ta
lc (section) // (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ( Ir1 SdNfi`
(please print)
Signature V Title ifi lg9T.
(over)
DOH-1555 (02/2004)