Merry, Raymond 1,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond H. Merry Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/12/1990 41 War or Dates
i- Place of Death Hospital, Institution or
W CitY,ROWAYCIRSt Schenectady Street Address Ellis Hospital
a Manner of Death❑ Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
n Circumstances Investigation
W Medical Certifier Name Title
C
Address
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
['Entombment
Address
pi ❑Cremation _
Date Place Removed
Z ri Removal and/or Held
and/or
H Address„
fa
Hold
0 Date Point of
eTransportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
❑X Disinterment 05/22/2018 St. Anthony's Cemetery, Glenville, NY
Date Cemetery Address
E Reinterment 05/23/2018 Pineview Cemetery, Glens Falls, NY
Permit Issued to Re8l i ttiion Number
Name of Funeral Home Townley & Wheeler Funeral Home
Address
21 Midline Road, Ballston Lake, NY 12019
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
ft
Ui
CL
Permission is hereby granted to dispose of the human remains desc ed above as indi ted.
Date Issued 05/15/2018 Registrar of Vital Statistics :.`L _
(s! nature)
District Number 4651 Place Glenville
i- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
til Date of Disposition 5/23/201 Blace of Disposition Pine View Cemetery Queensbury NY
2 (address)
lOCO Horicon 15-A 1
CC (section) (lot number) (grave number)
QName of Se on or Person in Charge of Premises Conni P Goedert
(please print)
14 ' e - f_tet4,r
Signature
Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)