Weidner, Rufus tt-21(4
NEW YORK STATE DEPARTMENT OF HEALTH � ,Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rufus Frank Weidner Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/24/2011 88 years War or Dates 1943-1946
1 P : e of Death Hospital, Institution or
Towp j(il XX Glens Falls Street Address The Pines
Manner of Death yVatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ili Circumstances Investigation
ig Medical Certifier Name Title
P. Named A. Siddioui MD
Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
It TowRJj(iIXXX Glens Falls 5601 248
rial Date Cemetery or Crematory
❑Entombment 05/25/2011 Pine View Crematory
igidii Address •
iiV IgiCtyemation Queensbury, NY
Date Place Removed
Z Removal and/or Held
la❑and/or Address
E=` Hold
Cl)
- 0 Date Point of
5 El Transportation Shipment
L by Common Destination
Carrier
❑Disinterment Date Cemetery Address
iiiali
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
git 11 Lafayette Street Queensbury, N Y 12804
lig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
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` Permission is hereby granted to dispose of the human remains described above as indicated.
iiii
'`< Date Issued 05/25/2011 Registrar of Vital Statistics (A..) Ckk.)6.,. "A)
i\j•-cj,fx,V1--
(signat e)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition ti l2bIII Place of Disposition {.szUj I t ziatwL.
2 (address)
lL
CA
CC (section) 4 (lo numb r) (grave number)
0
c Name of Sexton or Per on in Charge, f Premises t LSkir G
Ali► 111L.
( ease print)
• Signature Title �h,Ehik 4
(over)
DOH-1555 (02/2004)