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Rudolph, Richard J 161(...11—F) It i 7 8 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard J Rudolph Male Date of Death Age If Veteran of U.S.Armed Forces, 02/09/2024 71 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital IJJ `p Manner of Death aNaturalCause []Accident El Homicide []Suicide Undetermined ❑Pending C.) Circumstances Investigation W Medical Certifier Name Title Asim Chaudry MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 82 Burial Date Cemetery,Crematory or Facility Name 02/12/2024 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York Donation 0❑Removal Date Place Removed and/or and/or Held f- Hold Address N 0 d Date Point of (/)ETransportation p by Common Shipment Carrier Destination o Disinterment Date Cemetery Address Date Cemetery Address []Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above 5 Address CC W 0" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/12/2024 Registrar of Vital Statistics Megan Nolin(Electronically Signed) (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition Zi 13I iy Place of Disposition f iri v+rJ (4-n111 7► 44-- ILI 2 (address) W U) CC (section) f (lot number) (grave number) • Name of Sexton or Person in Charge)P ises71 `t U, ft Z h, (please prin� W Signature �. Title 1V14' (" DOH-1555(07/18)p I.of 2