Champagne, Judy NEW YORK STATE DEPARTMENT OF HEALTH 4 ? C-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Judy Ann Champagne Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/11/2014 60 years War or Dates
Place of Death Hospital, Institution or
ta City, TowmgrAtiltiMOC Glens Falls Street Address Glens Falls Hospital
p Manner of Death `�i�� Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
UE Circumstances Investigation
W Medical Certifier Name Title
O John P. Stauterburg M D
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TowQ)(XX'il )J( Glens Falls 5601 184
❑Burial Date Cemetery or Crematory
❑Entombment 04/15/2014 Pine View Cemetery
Address
11Qremation Oueensbury, NY 12804
Date Place Removed
Removal and/or Held
2❑and/or
F, Address
Cl)
Hold
d Date Point of
% 0 Transportation Shipment
Q by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
ig Address
82 Broadway, Fort Edward, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'; Address
f
W
it Permission is hereby granted to dispose of the human remains descr bed abov as i ed.
Date Issued 04/14/2014 Registrar of Vital Statistics
� .
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of inin accordance with this permit on:
LLI �Date of Disposition l IS i ii Place of Disposition
(address)
w
CC (section) (lot number) (grave number)
aName of Sexton or Person i Charge o PremisesA 3i
Zr (pie se print)
• Signature Title
(over)
DOH-1555 (02/2004)