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Rudolph, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit Name First Middle Last Sex Carolyn F. Rudolph Female Date of Death Age If Veteran of U.S. Armed Forces, July 29,2016 71 War or Dates i,,R Place of Death Hospital, Institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death I XI Natural Cause I I Accident I I Homicide Suicide Undetermined Pending W° Circumstances Investigation w Medical Certifier Name Title C Michael Fuller Address 100 Park St.,Glens Falls,NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 3 CIO ❑Burial Date Cemetery or Crematory August 1,2016 Pine View Crematory El Entombment Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold N 0 j Date Point of u) Transportation I Shipment p by Common Destination Carrier Disinterment Date I Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom F_ Remains are Shipped, If Other than Above 2 Address t : W O.' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ' 1 1 1 1-6 Registrar of Vital Statistics GAA4,1"-Q, (signatur District Number 560 I Place 6(.9..„\ s rej, l s,iv 7 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition g/3 1/J, Place of Disposition 40I4l �rwrc^`•-- 2 (address) W CO CZ (section) lot number) (grave number) pName of Sexton or Person in Charge of P emises Ai� StA.JtZ /1Q (please print) W Signature K Title /fligQ (over) DOH-1555 (02/2004)