Cudney, Madeline NEW YORK STATE DEPARTMENT OF HEALTH ' - - //a [
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Madeline M. Cudney Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/16/2016 100 ,War or Dates
} Place of Death 'Hospital, Institution or
Ti City, Tom)\iX Saratoga Springs Street Address Sarat a Hospital
a Manner of Death I Natural Cause El Accident Accident ❑Homicide ❑Suicide Undetermined ❑Pending
LU Circumstances Investigation
ui Medical Certifier Name Title
0 Maria Vivenzio M f)
Address
Death Certificate Filed District Number Register Number
'' City, TcP0X1XX' X Saratoga Springs 4501 445
❑Burial Date Cemetery or Crematory
❑Entombment 09/19/2016 Pineview Crematory
Address
[ Cremation Queensbury, N Y
Date Place Removed
Z �Removal and/or Held
and/or Address
F= Hold
tit?
O Date Point of
t"0 Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
= ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
fir.
t
,.' Permission is hereby granted to dispose of the human remain esc ' =overt ' icated.
Date Issued 09/19/2016 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
lf-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �(/�rf t Date of Disposition Viola, Place of Disposition n.iuLINO 61.,M tll'''•
', ► (address)
Ui
tfl
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises l�ipkr --)044
�r (pl ase print)
„...:.„ Signature a111 Title Cftkfre
(over)
DOH-1555 (02/2004)