Green, Rudy ti
NEW YORK STATE DEPARTMENT OF HEALTH �
�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rudy George Green Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 29,2011 59 War or Dates
1_ Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
V Circumstances Investigation
G: Medical Certifier Name Title
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Address
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Death Certificate Filed District Number Register-
Number
City, Town or Village Glens Falls,NY 5601 - 4_...)
❑Burial Date Cemetery or Crematory
El Entombment January 26,2011 Pine View Crematory
Address
El Cremation Quaker Road, Queensbury,NY 12801
Date Place Removed
Z + 'Removal and/or Held
9 and/or Address
H Hold
N
0 _ Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01464
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i-- Remains are Shipped, If Other than Above
a Address
fr
O. Permission is hereby granted to dispose of the human remains describe a ov as ' ica
Date Issued 00%40// Registrar of Vital Statistics 4.
(signa ure)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition rE(51 libil
Place of Disposition 'RNA) it..► C 4f otl"'`
W (address)
N
ix
jt
Z Name of Sexton or P rson in Charge of Premises (section) ati-s Pr (iot ny ►b�e� (grave number)
(please print)
W
Signature is--
Title CRIlt0}i o11,
(over)
DOH-1555 (02/2004)