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Dudley Jr., Theron Basil NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Theron Basil Dudley Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 11/28/2021 74 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Undetermined Pending W © Natural Cause �Accident �Homicide �Suicide Circumstances Investigation W Medical Certifier Name Title a Mathew Varughese DO Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 548 ▪Burial Date Cemetery,Crematory or Facility Name 11/29/2021 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ElDonation O Removal Date Place Removed and/or and/or Held ~ Hold Address 0 O. Date Point of U) ❑Transportation Shipment © by Common Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway, Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above a Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/29/2021 Registrar of Vital Statistics Npbert Andrew Curtis(E(ectronicaltySigned) (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: IH Z Date of Disposition //-30-.2o Z/ Place of Disposition e, e eto C re me_4-D r- 2 (address) W Cr (section)` �/ (lot n mberl, (grave number) .0• Name of Sexton or Person in Charge o emises J�✓�/m 17/ ocl W l / (p tea int) Signature i Title DOH-1555(07/i8)p t of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 • r- , Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#