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Campinell, Jean I , ;it -,.. iliC NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jean I Campine!! Female Date of Death Age If Veteran of U.S.Armed Forces, 03/14/2023 81 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 22 Smith Street,Glens Falls,New York 12801 LU p Manner of Death El Natural Cause Accident Homicide Suicide Undetermined riPending W Circumstances Investigation WMedical Certifier Name Title a Noelle Stevens MD Address 100 Park Street,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 140 Burial Date Cemetery,Crematory or Facility Name 03/17/2023 Pine View Crematory -) Entombment _ Address ©Cremation Queensbury Town,New York Donation 1/ t 112 0❑Removal Date Place Removed �"`� and/or and/or Held N Hold Address 0 Date Point of (/)nTransportation Shipment $ by Common Carrier Destination O Disinterment Date Cemetery Address OReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above g Address CC uJ O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/16/2023 Registrar of Vital Statistics Megan Wolin(ECectronically Signed) (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: Z W Date of Disposition ?j-/e-Zoz,Place of Disposition p, NJe 0, e.,3 C f.-- ✓1j A f 2 (address) W U) CC (section) _ �% \ //otnnumber) (grave number) O Name of Sexton or Person in Charge of Pre ises /^ IC/4� ©.4 t, w (please print) Z W Signature A' Title oe-0---ti DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1 - " .- 1 17,"),- 1 ' Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#