Budner, Sophie NEW YORK STATE DEPARTMENT OF HEALTH k= .k 0 Z
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Sophie H. Budner Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 24, 2011 95 War or Dates
:I Place of Death I Hospital, Institution or
YZ City, Town or Village Queensbury 1 Street Address Stanton Nursing & Rehab Centre
cManner of Death Iv Natural Cause n Accident I I Homicide Suicide I j Undetermined Pending
LliCircumstances Investigation
lis Medical Certifier Nam Title
A LAWVI.Q..E LAo ALA
Address M , brCve.. CkA1 QK. ! 62j041'
Death Certificate Filed District Number R gister Number
City, Town or Village Queensbury I 5657 I 0
El Burial Date Cemetery or Crematory
❑Entombment February 28, 2011 Pine View Crematorium
Address
l Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
t" Hold
co
O Date I Point of
135 1 'Transportation Shipment
p by Common Destination
Carrier
pi Disinterment
Date I Cemetery Address
I I Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan & Potter 01675
Address
407 Bay Road,Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
"1.., Remains are Shipped, If Other than Above
;". Address
te
Iti
. Permission is hereby granted to dispose of the human r m 'ns described above a ass indicated.
.' Date Issued-1L 61{)U Registrar of Vital Statistics G . CsiN.,L,
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ui Date of Disposition 3- 1- k( Place of Disposition Pint�,,N.! Grir,.4 -Url
W (address)
N
pCZ (section) a (z lot number)( (grave number)
Name of Sexton or Person in Charge f Premises r,� natt
W (please print)
Signature /i L Title Ct2E Ah rfii d(L
(over)
DOH-1555(02/2004)