Budikunst, Bonnie ,. y,
NEW YORK STATE DEPARTMENT OF HEALTH It f.
Vital Records Section t"- .-4.,.) ; Burial - Transit Permit
Name First Middle Last Sex
Bonnie L Gudikunst Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/04/2013 68 years War or Dates
14. Place of Death Hospital, Institution or
ii City, TowRcjdiljXX Glens Falls Street Address Glens Falls Hospital
Manner of Death Elu Natural Cause 0 Accident 0 Homicide 0$icide riUndetermined r7 Pending
Circumstances Investigation
Ill Medical Certifier Name Title
ct Farhana Kamal M D
Address
Glens Falls Hospital 100 Park Street Glens Falls
Death Certificate Filed District Number Register Number
City, TowRXI ilj XXX Glens Falls 5601 336
',. :i EIBurial Date Cemetery or Crematory
[]Entombment 08/07/2013 Pine View Crematorium
Address
e]Cemation Queensbury, NY 12804
Date Place Removed
Z El❑Removal and/or Held
430 aHnd/or Address
CO
old
0 - Date Point of
[]Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
Address
11 Algonkin Street Ticonderoga, N Y Ptc63
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'„ Address
IZ
Ili
9' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/06/2013 Registrar of Vital Statistics J )C&_n.,, D A..).- t„ -
UU __ (signatur
District Number 56n1 Place Clans Falls N 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
17.
Z � Q�-�
ILI Date of Disposition %J°)1f L3 Place of Disposition '6�ne Cteve-ctorwi—
2 (address)
ill
Er (section) (lot number) (grave number)
1 tt �1
i Name of Sexton or Person in harge of Pre. ises J4'Atop
. ht" t�►rt6t
z / h(plea print)
Signature 14 Title Cf2'f'11o(d-
(over)
DOH-1555 (02/2004)