Campbell, Maryann NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
iit
Name First Middle s Last Sex
Maryann Campbell ""`'' Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/02/2021 91 Years War or Dates
t— Place of Death Hospital,Institution or
Z City,Town or Village Herkimer Village Street Address Folts Home
UJ
p Manner of Death 0 Natural Cause 0 Accident ❑Homicide n Suicide ❑Undetermined 0 Pending
W U Circumstances Investigation
WQ Medical Certifier Name
Amanda Baker
Address
104 N Washington St,Herkimer Village,New York 13350
Death Certificate Filed Distric :ber Register Number
City,Town or Village Herkimer Village 2124 02
ElBurial Date Cemetery,Crematory or Facility ,ame
01/05/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
ZO Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
4. Date Point of
U) 0 Transportation
O by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
f- Remains are Shipped,If Other than Above
Address
CC
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n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2021 Registrar of Vital Statistics Janet Marie facquayr(EYectronrcadj,Signed)
(signature)
District Number 2124 Place Herkimer Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ?(L.
itW Date of Disposition I �'1 t' Place of Disposition
2 (ad ress)
W
Cl) (section) (lot 7 'berl (grave number)
0 Name of Sexton or Person in Charge of Pr ise // tl Lit vl�fi
Z (please print)
W Signature /' l Title G fCC"
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 123
1J
Receipt
Human remains of J1I delivered on , 20
Pine View Cemetery Represe eral home named on burial permit
Official Fune c ors Reg..,.r License#