Campney, Mary NEW YORK STATE DEPARTMENT OF HEAL"H ` SA,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Theresa Campney Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 9, 2014 69 War or Dates
ZPlace of Death Hospital, Institution or
w City, Town or Village Hudson Falls Street Address 16 Labarge Street
W Manner of Death u Natural Cause El Accident El Homicide El Suicide ❑ Undetermined ri❑ Pending
U Circumstances Investigation
W` Medical Certifier Name Title
0 Dr. David Foote,
Address
340 Main Street, Hudson Falls, NY 12839
Death _ertificat -d District Number Register Number
City, Town or -• S -)d- 6 0
❑Burial '- e Cemetery or Crematory
August 13, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
., Hold
CO Date Point of
er„` ❑
p Transportation Shipment
CO by Common Destination
0 Carrier
ElDisinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
M Address
IX
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued u /�,�piy Registrar of Vital Statistics f7 L&.. a ,,Ct�t,.
5 // (signature)
District Number -7,74i Place jj 0-11 a _c T/l7'ic (4(Eh F US
FI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 08/13/2014 Place of Disposition Quaker Road Queensbury,NY 12804
M (address)
W
CO
(section) (lot number) (grave number)
z0 Name of Sexton or Person in Charge of remises kr ` .,�^''t
� / (please print)
w Signature �� Tit e I �u; ►trr4
(over)
DOH-1555 (02/2004)