Jett Jr., Raymond 4. y
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond E. Jett,Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 11, 2013 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines Of Glens Falls
p Manner of Death n Natural Cause Accident n Homicide --Suicide pi Undetermined Pending
WCircumstances Investigation
U.
ILI Medical Certifier Name Title
0 Suzanne Rayeski,MD
Address
Glens Falls,NY
Death Certificate Filed District Number RegisterNumber
City, Town or Village Glens Falls,NY 5601 71-
1=1 Burial Date Cemetery or Crematory
November 18, 2013 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or _-- -
Address
H Hold
u)
O Date Point of
NLI Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
• Address
W:
O.
Permission is hereby granted to dispose of the human rTains described above as indicat
Date Issued // /y/,�U[ Registrar of Vital Statistics �f—g—‘;j1 ")
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
wDate of Disposition Place of Disposition
L (address)
W
U)
CL (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises
Z (please print)
W
Signature Title
(over)
DOH-1555(02/2004)