Campagna, Catherine NEW YORK STATE DEPARTMENT OF HEALTH ♦ - b 2 0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Catherine M Campagna Female
": Date of Death Age If Veteran of U.S. Armed Forces,
:: May 11,2012 89 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
:� n Natural Cause n Accident n Homicide n Suicide n n g
W Circumstances Investigation
:W' Medical Certifier Name Title
O Roslyn Socalof,MD
Address
160 Sherman Ave.Queensbury,NY 12804
Death Certificate Filed District Numbe5601 Register Number
City, Town or Village Glens Falls 2 Z.i
❑Burial Date Cemetery or Crematory
❑Entombment May 14,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
I- Hold
N
O Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
=:? Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 Jr/6 i (2. Registrar of Vital Statistics l")Cti\52 W
(signature
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition y-f-it Place of Disposition .4V �r+l..jo1ram
2 (address)
W
N
CL (section) Aro.
(lot number' (grave number)
Q Name of Sexton or Person in Charg of Premises g inAtt
Z (please print)
W
Signature ailL Title G(f€dvyy}-
(over)
DOH-1555(02/2004)