Campbell, Allan E ,(1 ...
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NEW YORK STATE DEPARTMENT OF HEALTH ;..
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Allan E.Campbell Male
?+ Date of Death Age If Veteran of U.S.Armed Forces,
Sri 12/11/2022 79 Years War or Dates
`'`E,..- Place of Death Hospital,Institution or
• City,Town or Village Schroon Town Street Address 2002 Rt 9,Schroon Town,New York 12870
ILI
p Manner of Death Z Natural Cause ❑Accident El Homicide DSuicide Undetermined El Pending
WI—I Circumstances Investigation
W Medical Certifier Name Title
CI Melanie Duerr NP
Address
., 47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed Town Of Schroon District Number Register Number
City,Town or Village 1563 9
Burial Date Cemetery,Crematory or Facility Name
1. 12/13/2022 Pine View Crematory
Entombment Address
ElCremation Queensbury Town,New York
DDonation
Z Date Place Removed
0 Removal
and/or and/or Held
N Hold Address
U)
O
O. Date Point of
U) Transportation
ES Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
f= Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/13/2022 Registrar of Vital Statistics TatriciaSavarie(ECectronicaltySigned)
(signature)
District Number 1563 Place Town Of Schroon
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition /Z 74 -207L Place of Disposition � V
IV I;4-3 C rill, t -k
2 (address)
W
N
CC (section) �/ (lotpum r) (grave number/
O Name of Sexton or Person in Charge of Pre es —R p7/'�'f,,i7 �.(✓O/�1
z (please print)
W Signature —l-A/f Title leyr +-`leCT
DOH-1555(07/18)p i of 2
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#