Campbell, Tracy NEW YORK STATE DEPARTMENT OF HEALTH . i Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Tracy A. Campbell Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 11,2013 52 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 19 Queen Mary Drive
W Manner of Death ❑Natural Cause ❑Accident D Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
G Timothy Murphy
Address
52 Haviland Ave,Glens Falls,NY 12801
Death Certificate Filed Queensbury District Number Register Number
City, Town or Village 5657 1 ( )
❑Burial Date Cemetery or Crematory
September 13,2013 Pine View Crematorium
Entombment Address
®Cremation 21Quaker Road,Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
Hold
t!!
O Date Point of
NTransportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 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
i- Remains are Shipped, If Other than Above
Address
a' Permission is hereby`granted to dispose of the human rem ns described as as indicated.
Date Issue 6 t 3 ckY13 Registrar of Vital Statistics /-1
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � t ui Date of Disposition 111316 Place of Disposition Zi K btu
(address)
N
(section) / (lot n mbar) (' (grave number)
pName of Sexton or Pers n in Charge of remises fr!- J e►►c�l
Z (p print)
• Signature 1 Title t'f riCaC
(over)
DOH-1555(02/2004)