Kudan, Norman NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
xa€,
Norman Leo Kudan Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 29,2018 96 War or Dates Army Air Co rs
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 81 Fort Amherst Road
Manner of Death FX-]Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Dr Sawyer,MD
Address
Queensbury,NY
Death Certificate Filed District Number I Register Number
City, Town or Village 5601
®Burial Date Cemetery or Crematory
❑Entombmerrt October 3,2018 Shaaray Tefila
Address
El Cremation Media Drive, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
F' Hold
N
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
FIT
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains des ribed abo as c tad.
Date Issued ?A Registrar of Vital Statistics
10 (signat re)
District Number S(oQ j Place
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
uj Date of Disposition 4 )-7 Place of Disposition
W (address)
CO)
W (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of remises
(Z (please print)
Signature Title
(over)
DOH-1555(02/2004)