Rudio, Carl NEW YORK STATE DEPARTMENT OF HEALTH / ) h Yri
Vital Records Section Burial - Transit Permit
777
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Name First Middle Last Sex
Carl G. Rudio Male
Date of Death Age If Veteran of U.S. Armed Forces,
K 4 June 14, 2015 84 War or Dates
I Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 69 Crane Court
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
.T Medical Certifier Name Title
Christopher Messitt, Dr.
Address
135 North Road Gansevoort, NY 12831
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5(,51 1O4-{-
❑Burial Date Cemetery or Crematory
June 15, 2015 Pine View Crematory
7 <❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
. ❑ Removal and/or Held
Y = and/or Address
Hold
a- Date Point of
,
.;I I Transportation Shipment
, , byCommon
Destination
Carrier
_, ❑ Disinterment Date Cemetery Address
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❑ Reinterment Date Cemetery Address
»Sel e Permit Issued to Registration Number
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..— Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
VI 82 Broadway, Fort Edward NY 12828
k Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human remai s described above as indicated.
Date Issued (p- 15- ao 15 Registrar of Vital Statistics • (Z LL 't 'e. ----'
'" `` (signature)
. District Number 5-(.,51 Place Qv c c n s blilij
PI I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/15/2015 Place of Disposition Quaker Road Queensbury,NY 12804
r
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Char a of Premises t `_ St.+ r
(p ase print)
Signature Title (.'rZFMVtI 14.
(over)
DOH-1555 (02/2004)