Rose, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Joseph Rose M
Date of Death Age If Veteran of U.S. Armed Forces,
05/02/2014 69 War or Dates 1964-1970
I-- Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ILIW Manner of Death❑x Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Lu Medical Certifier Name Title
II Suzanne Blood MD
Address
Moreau Family Health Center Route 9, South Glens Falls,NY 12803
Death Certificate Filed District Number Register um er
City, Town or Village Glens Falls 56g/ /6
❑Burial Date Cemetery or Crematory
05/05/2014 Pineview Crematory
['Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
F.- Hold
Cl)
0 Date Point of
o Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
CC
ILI
` Permission is hereby ante to dispose of the human remain describe above as i i icat ..
Date Issued 0/ Registrar of Vital Statistics G Yt . UL--<._..
(signature)
District Number56"0/ Place 61l,f ,,k-t17
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IW Date of Disposition 5A0 f/y Place of Disposition a'(►nt�aw 6 :t,�-
p
LEI
(address)
to
cc (section) (lot number) (grave number)
a Name of Sexton or Per n in Charge of Premises 5--
iJAl
( ease print)
iii
Signature L.-- '4 .Title C1IE041tf
(over)
DOH-1555 (02/2004)