Dunklee, Raymond NEW YORK STATE DEPARTMENT OF HEALTH o �"
Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
f r Ra mond B. Dunklee Male
Date of Death Age If Veteran of U.S. Armed Forces,
., January 24, 2016 95 War or Dates
Y Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death
1X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Way MD
Address
0ti100 Park Street,Glens Falls,NY 12801
:r r Death Certificate Filed District Number Register,,yynnber
"� City, Town or Village f`�j
,;�� Y 9 Glens Falls 5601
❑Burial Date Cemetery or Crematory
El Entombment January 27,2016 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
0 and/or Address
Hold
Cl)
0 Date Point of
NI ]Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
'.;, Name of Funeral Home Regan Denny Stafford Funeral Home 01443
r$ Address
:'r?:': 53 Quaker Road, Queensbury,NY 12804
,:•:# Name of Funeral Firm Making Disposition or to Whom
' : Remains are Shipped, If Other than Above
Address
:.d Permission is hereby granted to dispose of the human remains de cr'be a ve dicated.
1
:: Date Issued 0//7/.col.' Registrar of Vital Statistics
{t•
(signature)
District Number 5601 Place Glens Falls
•
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I/Zq/J(, Place of Disposition -gicL G 4't'w'`
2 (address)
W
U)
W
(section) A. (lot num ) (grave number)
a Name of Sexton or Person in Charge of Premises (hi,, ,r�►ict
Z /1 1 (please print)
la
Signature W'- jrf, Title itzeilifinit
(over)
DOH-1555(02/2004)