Rudolph, Eugene A. / I %
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Eugene A.Rudolph Male
Date of Death Age If Veteran of U.S.Armed Forces; a
A: 01/20/2021 86 Years War or Dates
Place of Death
Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death XI NaturalCause ElAccident ❑Homicide ElSuicide ❑Undetermined ❑Pending
Circumstances Investigation
W• Medical Certifier Name Title
D
William Cleaver MD
Address
S.: 100 Park St,Glens Falls,New York 12801
r�
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 55
, ❑Burial Date Cemetery,Crematory or Facility Name
>'{ 01/26/2021 Pine View Crematory
❑Entombment Address -
;' Cremation Queensbury Town,New York
❑Donation
Z Date Place Removed
O ❑Removal and/or Held
�-1_ and/or
Hold Address
O--
a
CO ❑Transportation Date Point of
O by Common Shipment
a� Carrier Destination
-'4, ❑Disinterment Date Cemetery Address
-k.,
r=;❑Reinterment
Date Cemetery Address
,- Permit Issued to Registration Number
1.2 Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped,If Other than Above
g Address
CC
W
- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/26/2021 Registrar of Vital Statistics 2i'96ertAnddrew Curtis(E(ectronicat y Signed)
(signature)
:.' District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W l
Z Date of Disposition I/11 I Z) Place of Disposition � �L 7.4L_
2 (address)
W
Cl)
CC (section) ( t number) (grave number)
fl0 Name of Sexton or Person in Charge of Premises a►r•� l- `�""+�'�/
U (p/easerint)
Signature �� Title r112( 1W
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014 4 62
Receipt
Human remains of delivered on , 20
J `!
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ',.)