Rohne, Raymond e
I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
%•• Name First Middle Last Sex
f•: Raymond W. Rohne Male
'rf Date of Death Age If Veteran of U.S. Armed Forces,
• September 23, 2015 80 War or Dates
. ' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
�, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
g Circumstances Investigation
Medical Certifier Name Title
*. Amy Hogan-Moulton Dr.
*: Address
:'r 2 Broad Street Plaza,Glens Falls,NY 12801
:. Death Certificate Filed District Number Register Number
. City, Town or Village Glens Falls 5601
❑R Burial Date Cemetery or Crematory
❑Entombment September 28, 2015 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
OI I Removal and/or Held
and/or Address
F"' Hold
W
0 Date Point of
a.
(0 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
:;s Permit Issued to Registration Number
:;r Name of Funeral Home Regan Denny Stafford Funeral Home 01443
i:§: Address
53 Quaker Road,Queensbury,NY 12804
;; ; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r(mains d cribed a ove as ind' ate .
::.: Date Issued 07
/ Registrar of Vital Statistics 42'7 7. f k)-�'
(signature)
*I':' District Number 6--be/ Place r,� // r
I certify that the remains of the decedent identified above were disposed of in a ordance with this permit on:
W Date of Disposition 9/28/1 5 Place of Disposition Pine View Cemetery, Queensbury, NY
W (address)
CO Huron 10B 6
(section) (lot number) (grave number)
O Name of Sext n or Person in Charge of Premises
G 9 Conn i P T,_ Gnc�riPrt
2 (please print)
W Signature -�J lL, e. , v Title Cemetery Superintendent
(over)
DOH-1555(02/2004)