Gorham, Raymond NEW YORK STATE DEPARTMENT OF HEALTH 511u
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond P. Gorham Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 2, 2011 72 War or Dates V _lo g,_ 95e - c-2 b,9—Ng�a'
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 62 East Street
Manner of Death ElNatural Cause ID Accident El Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
i IT
Circumstances Investigation
ir Medical Certifier Name Title
Bernardo R Villajuan, Dr.
Address
48 East Street Fort Edward, NY 12828
. Death Certificate Filed Distric umber Regis Number
,' City, Town or Village
0 Burial Date Cemetery or Crematory
October 7, 2011 Pine View
0 Entombment Address
-;,,,i ElCremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold f
Date Point of
❑Transportation Shipment
by Common Destination
0-0 Carrier
.., Date Cemetery Address
❑ Disinterment
ate:
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
:. Name of Funeral Home M. B. Kilmer Funeral Home 01079
vii, Address
82 Broadway, Fort Edward NY 12828
-0, Name of Funeral Firm Making Disposition or to Whom
:v= Remains are Shipped, If Other than Above
Address
%_; Permission is her by ranted to dispose of the human "ns decrib d boy as indicated.
Date Issued/ C�// Registrar of Vital Statisti �J/
(signatu
District Number Place ��Gjju
I certify that the remains of the decedent identified ove were disposed of in accordance with this permit on:
Date of Disposition 10/07/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
` (section) ii (lot fie
(grave number)
Name of Sexton or Person in Charge of Premises I►'h viF by ��e v.A P Ge
, ,� / (please print)
tj Signature Title r
—TAT
(over)
DOH-1555 (02/2004)