Lamoureux, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section �► Burial - Transit Permi °�
Name First Middle Last Sex
Raymond J Lamoureux Male
Date of Death Age If Veteran of U.S.Armed Forces,
F. September 2, 2011 l War or Dates
2 Place of Death •' Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death rg Natural Cause 0 Accident D Homicide Suicide 0 Undetermined 0 Pending
�t Circumstances Investigation
U Medical Certifier Name Title
Dr. Matthew Varughese, M.D. Dr.
(1 Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5 ° 3 9
❑Burial Date Cemetery or Crematory
September 8, 2011 Pineview Crematorium
❑Entombment Address
Cremation Town of Queensbury Queensbury, NY 12804
Date Place Removed
4 Ei Removal and/or Held
and/or Address
Hold
Date ` Point of
QTransportation Shipment
by Common Destination
Carrier
Date Cemetery Address
Disinterment
�I Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
1-
Name of Funeral Firm Making Disposition or to Whom
M Remains are Shipped, If Other than Above
Cr
W Address
0.
Permission is hereby granted to dispose of the human remains described above as-indicated.
Date Issued 4 / 0 6 j 1, Registrar of Vital Statistics Q/ Q
(signature)
District Number 5 (7o Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
wDate of Disposition 09/08/2011 Place of Disposition Pineview Crematorium
2 (address)
fl (section) • (lot number) (grave number)
2 Name of Sexton or Perso in Charge of P mises I4ri9(l f' ' IKNIt
W (please print)
Signature Title reFw Q
(over)
DOH-1555 (02/2004)