Rutledge, John NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section t . t Burial - Transit Permit
Name First Middle Last Sex
John Noel Rutledge Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/ /20t12 67 years War or Dates 1968- 1970
Place o ea h Hospital, Institution or
Z y, wX Street Address ��s
▪ Mannerl o- ' ,i'• X Clcns F.-ills,, C Ions undetermined Hospital
Natural Cause Accident ❑Homicide ❑Suicide ❑Pending
W v Circumstances Investigation
ill Medical Certifier Name Title
iC
Add eoo crt Sponzo M. D.
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TowTovizki/ikgX Glens Falls 5601 355
51 El Burial ate Cemetery or Crematory
21111 El Entombment Address07126!2012 Pineview Crematory
❑Cfemation Queensbury, N Y 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
Hold
V)
0 Date Point of
toll ❑Transportation Shipment
O by Common Destination
Carrier
gE: ❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 I afayette Strap!. (JuPPnshury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
LU
` Permission is hereby granted to dispose of the human remains described ab ve a indi
Date Issued 07/26/2012 Registrar of Vital Statistics 'Z`
(signature)
District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition 7_ i Z Place of Disposition ',yi< V .f,;,) CPt,.40-7C1 c,r y
a (address)
LEE
i
CC (section (lot number) (grave number)
CI• Name of Sexton or Person in Charge f Premises i 3c.. L
�-- y :.,t l(please print)
Signature Title Cf-e Yvic.A brc PS$ .
(over)
DOH-1555 (02/2004)