Crum Sr, Raymond 4 1
NEW YORK STATE DEPARTMENT OF HEALTH 0.3
Vital Records Section Burial - Transit Permit
t T Name First Middle. Last / Sex
Raymond Arthur •. Crum Sr Male
Date of Death - Age I If Veteran of U.S. Armed Forces.
8/30/2016 i 63 ! War or Dates -
I —
1—, Place of Death I Hospital. institution or
M_city. Town or Viliage Glens Falls I Street Address Glens Falls Hospital
_ _ .
Manner of Death r71
trj Natural Cause 0 Accident D Homicide D Suicide n Undetermined ri Pending
Circumstances 4...'a Investigation
w Medical Certifier Name Title
David Foote
Address
340 Main Street 12839 _ _ ..
Death Certificate Filed i District Number cool i Register Number iiiiq
City, Town or Village Glens Falls ',., i
DBuriat Date -,i Cemetery or Crematory
I
9/1/2016 I Pine View Crematory
0Entorribmentr— '
DCremation 21 Quaker Road,Queensbury New York 12804
, - - ,
Date r Place Removed
[j ' .
Z Removal
ess--- and/or Held
° and/or .
Hold
. _..„_„.._ .
I Date Point of
ft 0 Transportation 1 Shipment
by Common ! Destination
Carrier
Date Cemetery Address
D Disinterment i
Date Cemetery Address
0 Reinterment '
,
, .
Permit Issued to ', Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home - South Glens Falls 01078
Address
136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shi If Other than Above
2 Address
CC
. \
11' Permission Is /hereb granted to dispose of the human remains described abate as indica . ./.
Date Issued 07 0/ 4;)/4. Registrar of Vital Statistics
(
(X:, ../
signature) —__
District Number ,,, Place /,, 6:-,-L4
in... I certify that the remains of the decedent identified above were disposed of i accord ape with this permit on:
Mk Date of Disposition 7/1//4 Place of Disposition eCtd
(address)
(section)
Name of Sexton or Person in Charge of Premises ___ _ /4111171,---(1°"4tmbir3jt (grave nulnber)
Z ( se print)
at Pill lit,
Signature a •,(
itj 1...-- Title
(over)
DOH-1555(02(2004)