Havens, Raymond NEW YORK STATE DEPARTMENT OF'HEALTH 4 31
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Havens Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 27, 2016 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
AgeelA. Gillani, M.D. Dr.
Address
,. 102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 2d J 0 7y
t❑Burial Date Cemetery or Crematory
May 27, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
5 i;❑ Removal and/or Held
and/or Address
E Hold
04 Date Point of
�C ❑Transportation Shipment
by Common Destination
a Carrier
z Disinterment Date Cemetery Address
IIIReinterment Date Cemetery Address
Permit Issued to Registration Number
,g Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
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 remains described above as indicated.
Date Issued , /*2_7 / /CRegistrar of Vital Statistics - z UU/'-
(signature)
District Number j C-r' / Place e�C.A,.\5 vita ‘. \ S i Ni
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/27/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) filpt number) (grave number)
Name of Sexton or Person in Charge of P emises rv- t
''�� (piase print)) f
Signature 6 most Title 1 Pi(
(over)
DOH-1555 (02/2004)