Dove, Raymond It
NEW YORK STATE DEPARTMENT OF HEALTH �t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Pershing Dove Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 10, 2012 93 War or Dates World War II
t. Place of Death Hospital, Institution or
iii City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
ai Manner of Death El Natural Cause ❑ Accident ❑ Homicide E Suicide 1-7 Undetermined El❑ Pending
ILI
o Circumstances Investigation
9 Medical Certifier Name Title
Nawed A. Siddiqui, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Nupr Register Number
City, Town or Village `'j 73� CO
❑Burial Date Cemetery or Crematory
February 10, 2012 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
0. ❑Transportation Shipment
CO, by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
III Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
Permission is h reby ranted to dispose of the human ins describ d bove indicated.
Date Issue , .-- Registrar of Vital Statisti 1 V/
.—/ — - (signature)
District Numbers 7�.� Place / d�i� e
I certify that the remainsof the decedent identified above were disposed of in accordance with this permit on:
4' Date of Disposition 02/10/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
IZ (section) 4/ - (lot number) r (grave number)
Ci Name of Sexton or Per p in Charg of Premises ( .,S} r Q.�+ff-
3 % (please print)
au Signature t Title Ca631 L4-t-t
(over)
DOH-1555 (02/2004)