Malloy, Raymond bob 4-e--
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Molloy Male
Date of Death Age If Veteran of U.S.Armed Forces,
i. January 3, 2006 64 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Fort Edward Street Address Mc Crea Hotel
0 Manner of Death ❑ Natural Cause ❑Accident ❑Homicide ESuicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W
Q Address
Death Certificate Filed District
Number
Register Number
City,Town or Village Fort Edward
❑Burial Date Cemetery or Crematory
January 9, 2006 Pine View Crematory
❑Entombment Address
2 ❑X Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
and/or Address
Hold
0 Date Point of
0 ❑Transportation Shipment
A by Common Destination
i Carrier
Date Cemetery Address
^ ❑ Disinterment
�I El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01142
Address
82 Broadway, Fort Edward, New York 12828
1- Name of Funeral Firm Making Disposition or to Whom
ce• Remains are Shipped, If Other than Above
W Address
O.
Permission is h reb granted to dispose of the human re ains described above s indicated.
Date Issued / 5 Registrar of Vital Statistics �/yjl j ,/�p
G (signature)
�1 -(/
District Number 57cQ/— Place Fort Edward,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 01/09/2006 Place of Disposition Pine View Crematory
2 (address)
W
th
I (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises C hr‘S Sp h n t I71"
�i (please print)
Title C ce,,.c-NriC
(over)
DOH-1555 (02/2004)