Champagne, Harold NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harold J. Champagne, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
8/19/95 73 War or Dates WWII
Place of Death Hospital, Institution or
CityxT6i&AxefxANTexx Saratoga Springs Street Address Saratoga Hospital
Manner of Death®x Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
A. Circumstances Investigation
Medical Certifier Name Title
George Siniapkin M.D.
Address
Palmer Ave. , Corinth.
Death Certificate Filed District Number Register Number
Citv' :fff"VrMbkaQec Saratoga Springs 4501
Date Cemetery or Crematory
❑Burial 8/21/95 Pine View Crematory
Address
0 Cremation Queenshury,, NY
Date Place Removed
Z ❑Removal and/or Held
0 and/or Address
Hold
O Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc 00223
Address
5826 Church St. , Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ns bed - o a led.
Date Issued 8/21/95 Registrar of Vital Statistics •
(signature)
District Number 4501 Place Department of Public Safety, Saratoga Springs, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition
.2 (address)
LIJ
tion)
�(lot } (grave number)
� Name of Sexton r Person Charge of Pr rises
g (please print) f
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61