Campney Jr, Charles NEW YORK STATE DEPARTMENT OF HEALTH 959
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles M. Campney, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/18/2015 48 yrs. War or Dates 1985 - 1992
Place of Death Town of Hospital, Institution or
Wooded area off of
5 City, Town or Village Ticonderoga Street Address
g Shore Airport Road
ci Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Circumstances Investigation
ill Medical Certifier Name Title
Eric Gorman M.D.
Address
CVPH Medical Center, Plattsburgh, NY
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 3
"" ❑Burial Date Cemetery or Crematory •
06/19/2015 Pine View Crematory
❑Entombment Address
;Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
i= Hold
an
O Date Point of
I:LTransportation Shipment
ei by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Date Cemetery Address
0 E Reinterment
>': Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
" Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
f
P.:. Permission is hereby granted to dispose of the human remai s escribed ab v as in is ted.
iU
Date Issued. 6/1 9/2 01 5 Registrar of Vital Statistics ,ftl- \ v ,'r/Y\
(signature)
gi District Number Place
1564 Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k''`
fU Date of Disposition (o--Z-I Place of Disposition Pile U:e Cf<vvxQ(or; :A-1
Z. (address)
iii
VI
CC
(section (lot number) (grave number)
I Name of Sexton or erson in ,, arge of Premises t,:w3 o`t I►Y rk,fie h
z
(please print)
Signature `.& / Title Cueing-4 err 44.s/•
—
(over)
DOH-1555 (02/2004)
1