Campbell, Diane li ), # 81g
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
. Name First Middle Last Sex
DIANE M. CAMPBELL FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
11/13/2016 62 War or Dates NO
} Place of Death Hospital, Institution
Z
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
its Manner of Death ® Natural ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
ili Cause Circumstances Investigation
Medical Certifier NameLU Title
C SEAN P. GEARY MD
Address
43 NEW SCOTLAND AVE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 2383
Date Cemetery or Crematory
❑ Burial 11/15/2016 PINEVIEW CREMATORY
0 Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0 El and/or Address
Hold
Cl)
0 Date Point of
CL Transportation Shipment
CO ❑ By Common Destination
ES Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑
Reinterment
Permit Issued To Registration Number
Name of Funeral Home DENSMORE FUNERAL HOME 00448
Address
7 SHERMAN AVE CORINTH NY 12822
Name of Funeral Firm Making Disposition or to Whom
, Remains are Shipped, If Other than Above
2; Address
W'
11- Permission is hereby granted to dispose of the human remains descpbe ab ve as indicated.
Date 11/15/2016 5l-OIL , <C_- - -c�--1 \r .CZ
Registrar of Vital Statistics
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordanceor with this permit on:
Date of Disposition fj',WWI Place of Disposition '(neaJ t.- (icshnOt®ria....
w (address)
2
tuco
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re (section) (lot number) (grave number)
W CI
Name of Sexton or Person in Charge of Premises /fin, ,,-. .St4i
(please print) (P
Signature l[ ,r4(It Title CPC AfiTO(I—
(over)
DOH-1555 (02/2004)