Campney, Tena Marie NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Tena Marie Campney Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/18/2022 67 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
IU
p Manner of Death Natural Cause Accident El Homicide OSuicide FlUndetermined Pending
W
0 Circumstances Investigation
WC Medical Certifier Name Title
Bo Li MD
Address
100 100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 534
Burial Date Cemetery,Crematory or Facility Name
10/20/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
OElRemoval Date Place Removed
F and/or and/or Held
a Hold Address
O. Date Point of
M❑Transportation Shipment
S by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
a Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/20/2022 Registrar of Vital Statistics Megan Wolin(ECectronica1TySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /o 1711 72 Place of Disposition htv� 4 rs,—___
W (address)
W
EC (section) /J�"(lot number) (grave number)
8 Name of Sexton or Person in Charge of ises /jl ' ("- fT
//� /p as'e print)
W � L--� Title 6260if
Signature
DOH-1555(o7/t8)p 1 of 2
7
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#