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Dudley, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH t . 4 3-) Vital Records Section Burial - Transit Permit Name First Middle Last Sex Kathleen L. Dudley Female Date of Death Age If Veteran of U.S. Armed Forces, July 17,2012 59 War or Dates Place of Death Hospital, InstitutiorMirondack Tri-County Health Care . . City, Town or Village Johnsburg Street Address Center la .a Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending AU Circumstances Investigation w Medical Certifier Name Title ©' 4 ‘c)or;c'bd01 MV Address Death Certificate Filed District Number Register Number City, Town or Village Johnsburg 5655 c2 7 ❑Burial Date Cemetery or Crematory July 18,2012 Pine View Crematory 0 Entombment Address ®Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold N 0 Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address n Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom ,H Remains are Shipped, If Other than Above ZAddress tit Permission is hereby granted to dispose of the human rem ins describe ove as indicated. Date Issued 07/1 //2o Registrar of Vital Statistics ..-Le .e TC( _ (signature) District Number 5655 Place Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z /� • Li Date of Disposition '1-t0-�7, Place of Disposition �•,.i,t/ . / otr,,.- W (address) Cl) cc (section) (lotumber)c (grave number) " pName of Sexton or Person in Charge f Premises �jr,i1 r 3l4nif' Z (please print) W Signature d1.,, Title Cacnnr,o,2 (over) DOH-1555 (02/2004)