Champion, Thelma E # iii 1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thelma E Champion Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/07/2022 97 Years War or Dates
F., Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death a Natural Cause Accident Homicide Suicide FlUndetermined ❑Pending
IllC.) Circumstances Investigation
W Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 95
Burial Date Cemetery,Crematory or Facility Name
06/09/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
ZO❑Removal Date; Place Removed
and/or and/or Held
F- Hold Address
N
0
CL Date Point of
U)0Transportation Shipment
p by Common
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i.. Remains are Shipped,If Other than Above
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/09/2022 Registrar of Vital Statistics Caroline.fififegarrfeBar6er(ECectronica(TySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Il— �
Z Date of Disposition (4)ol aPlace of Disposition "V"e u
W (address)
W
NCC (section) AIL_
(lot number) (grave number)
Name of Sexton or Person in Charge Pre ises T `c,4Z o se print) �,�r
W i nature of � / ` Title �l'E/A'Tl0t
Signature
DOH-1555(o7/18)p 1 of 2
5778
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#