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Oudekerk, Dale NEW YORK STATE DEPARTMENT OF HEALTH if Z/g Vital Records Section Burial - Transit Permit Name First Middle Last Sex Dale Oudekerk Male Date of Death Age If Veteran of U.S. Armed Forces, April 26, 2014 54 War or Dates Place of Death Hospital, Institution or it City, Town or Village Glens Falls Street Address Glens Falls Hospital Cr Manner of Death 171 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending 0- Circumstances Investigation ILL Medical Certifier Name Title CI David Foote Md, Address z =; Rt 4 Hudson Falls, NY 12839 Death Certificate Filed District Number Register Number = .. City, Town or Village 5-6©/ v2G0 _ ❑Burial Date Cemetery or Crematory May 5, 2014 Pine View Crematorium ❑Entombment Address ' ''OCremation Quaker Road Queensbury,NY 12804 Date Place Removed z. ❑ Removal and/or Held and/or Address �:. Hold TAO Date Point of :a.., Li Transportation Shipment 0) by Common Destination Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address El Reinterment ' Permit Issued to Registration Number , Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ':' Address iri lli:. ®' Permission is hereby ranted to dispose of the human remains describ d b ve in d. Date Issued . 09/�/Y Registrar of Vital Statistics ���� A7 / (signature) District Number S '/ Place t/Pti,e /65, /U7 certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W: Date of Disposition 05/05/2014 Place of Disposition Quaker Road Queensbury,NY 12804 (address) Ut a (section) _ (lot nu er) (grave number) 0 CI Name of Sexton or Person Charge of Premises is n ( 4 ✓ (please print) t Signature Title 02Cifi € (over) DOH-1555 (02/2004)