Rummel, Anne NEW YORK STATE DEPARTMENT OF HEALTH 37 I
Vital Records Section Burial - ransit Permit
Name First Middle Last Sex
Anne E. Rummel Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/13/2016 82 years War or Dates
j— Place of Death Hospital, Institution or
W City' X T XXr lu IXl ( Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide pi❑Undetermined 17❑Pending
Circumstances Investigation
ut Medical Certifier Name Title
1 Mathew Varughese M D
Address
100 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TXr URA Glens Falls 5601 255
❑Burial Date Cemetery or Crematory
05/18/2016 Pine View Crematorium
❑Entombment Address
ii®Cremation Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
Q and/or Address
t: Hold
(ft
0 Date Point of
)El Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home, Inc. 00448
Address
7 Sherman Ave. Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
C
W
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/16/2016 Registrar of Vital Statistics (,,, �� y.� 1, u 1/�t1(signet e)
District Number 5601 Place Glens FallsIN ."f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,I
W Date of Disposition VIM. Place of Disposition tf iL..., ( c ri,,,
(address)
LU
CO
CC (section) ` rj7'lot numbeG� (grave number)
ga Name of Sexton or Person in Charge of remises �' rI�L
2 (please print)
iij a
:.:„:„, Signature -7 Title 44177--
(over)
DOH-1555 (02/2004)