Fisher, Dudley NEW YORK STATE DEPARTMENT OF HEALTH / E5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dudley L. Fisher Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/27/2017 78 years War or Dates
li- Place of Death Hospital, Institution or
City, To9tXXX\h( XX (X Saratoga Springs Street Address Mary's Haven, 35 New Street
0 Manner of Death❑,3Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
ut Medical Certifier Name Title
Vincent Meyer Md
Address
Death Certificate Filed District Number Register Number
City, ToXX CVAlktXX Saratoga Springs 4501 312
❑Burial Date Cemetery or Crematory
06/27/2017 Pineview Crematory
['Entombment Address
❑+cremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2❑and/or Address
Hold
tR
O Date Point of
El Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home • • 00448
i> Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
/- Remains are Shipped, If Other than Above
• Address
cr.
l
• Permission is hereby granted to dispose of the human rem ce ed airy indicat d.
Date Issued 08/27/2017 Registrar of Vital Statistics M
(signature)
District Number 4501 Place Saratoga Springs
`•" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition min Place of Disposition Fis4L frositerre.--,2 (aess)
Ili
CC (section) , (lot number) (grave number)
0 Name of Sexton or Person in Charge of P; mises Jive I
r.
(pl se print)
la •
> Signatur
e Title prolix
(over)
DOH-1555 (02/2004)