Raymond Jr, Barry i ti,
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Barry Gene Raymond, ,Tr_ Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/27/2014 28 yrs. War or Dates No
:: Place of Death Town of Hospital, Institution or Hospital
Z City, Town or Village El i zahetht own Street Address Elizabethtown Community
0 Manner of Death Undetermined Pending
Natural Cause ®Accident �Homicide �Suicide � [�
til Circumstances Investigation
in Medical Certifier Name Title
0 C. Francis Varga M.D.
Address
P_O_ Box 768, Lake Placid, av 12946
Death Certificate Filed Town of District Number /_ Register Number,
City, Town or Village Elizabethtown ! S 5. LO
❑Burial Date Cemetery or Crematory
❑Entombment 12/31 /2014 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
.54 and/or Address
t= Hold
til
Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date • Cemetery Address
Permit Issued to Registration Number
ifii Name of Funeral Home Wilcox & Regan funeral home 01 821
iiiiiiiii Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
tr
to -
CL
` Permission is he eby ranted to dispose of the hum ains escribed a ye as' icated.
Date Issued /' /r Registrar of Vital Statistics —---
(signature)
District Number /6-` Place \M , p ef
iie I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I/Lf f% , Place of Disposition /Ns Gt„.,„� C or,�.
(address)
ILI
ilk
U. (section) (lot mber) c (grave number)
a
ct Name of Sexton or Person in Charge of Premises gr evrr7
(please pr t)
Signature Title c'IZ , flj
(over)
DOH-1555 (02/2004)