Smith, Raymond NEW YORK STATE DEPARTMENT OF HEALTH di}
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond James Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 27,2015 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause [ l Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
C] Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1 1 Li
❑Burial Date Cemetery or Crematory
March 5,2015 Pine View Crematory
0 Entombrnent Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
F' Hold
U)
O _ Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
pi Remains are Shipped, If Other than Above
2 Address
t
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 %Z / Is Registrar of Vital Statistics wCA Y- l,A)
(signature
District Number rj 6 0) Place Glens Falls J Ai
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 3)6115 Place of Disposition .e1�,,.r C, Or•w-.
III
(address)
CO
re (section) / (lot nu er) (grave number)
Q Name of Sexton or Person in Charge of Premises G 4/: [w'!J-
Z lease print)
w Signature / .1-7- Title Ca isi 6-la
(over)
DOH-1555 (02/2004)