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Runewicz, Theresa /rile NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Plermit Name First Middle Last Sex Theresa A.Runewicz Female Date of Death Age If Veteran of U.S. Armed Forces, 06/09/2018 49 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital e Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending , Circumstances Investigation w Medical Certifier Name Title Michael Adams MD Address 100 Park St,Glens Falls,New York 12801 ra Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 288 - ❑Burial Date Cemetery or Crematory 06/11/2018 Pine View Crematorium eit❑Entombment Address ®Cremation Queensbury, New York Date Place Removed t, ❑Removal and/or Held i. s and/or Address Hold Date Point of ;❑Transportation Shipment • by Common Destination til Carrieris _ ❑Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address • Permit Issued to Registration Number - Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Fi y. Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above -7- Address iPermission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/11/2018 Registrar of Vital Statistics 4416enA Curtis(Electronically Signed) (signature) mu.• District Number 5601 Place Glens Falls, New York Vvit I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 6,112. 11 Place of Disposition 40,-; (2tow,fogs—% (address) (section) A(lot number) (grave number) != Name of Sexton or Person in Charge of Premises !Ar,1 t-4 t ,a, (pl se print) ,k P 016,1itat Signature Title (over) DOH-1555 (02/2004)