Buchwald, Augusta NEW YORK STATE DEPARTMENT OF HEALTH it 3
Vital Records Section It
Burial - Transit Permit
Name First Middle Last Sex
Augusta Louise Buchwald Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 22 2013 97 War or Dates
I,.. Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
pManner of Death I XI Natural Cause ❑Accident n Homicide n Suicide l i Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
GI Philip Gasa Jr.MD
Address
327 Broadway,Ft.Edward,NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 770
❑Burial Date Cemetery or Crematory
November 29, 2013 Pine View Crematorium
❑Entombment Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
I' Hold
N
O Date Point of
N ElTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
ft
W
O.
Permission is he eb granted to dispose of the human r ins described bove s indicated.
Date Issued Registrar of Vital Statistic � ,,,,,?Le QL
(signature)
District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 4-3-i3 Place of Disposition Zia.) CV'.4 Cr --',-
2 (address)
W
CO
rL (section) dr)546,-
Z flonumber)� (grave number)
pName of Sexton or Person in Charge Premises ri.'4-
Signature ( lease print)
W Title (�
rg
(over)
DOH-1555(02/2004)