McCoy, Raymond ft
NEW YORK STATE DEPARTMENT OF HEALTH - #: r t -)35
Vital Records Section 1 Burial - Transit Permit
Name First Middle Last Sex
Raymond Lynn McCoy Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 4, 2013 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 196 Hinds Road
tY 9
_` Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
,A; Circumstances Investigation
Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number _ Register Number
City, Town or Village Argyle 5-A So 3-1
❑Burial Date Cemetery or Crematory
December 5, 2013 Pine View Crematory.❑Entombment Address
„t EjCremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
'. ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
;x Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,' Address
,
f x' Permission is hereby granted to dispose of the huma ains describ d above as 'ndicated.
7 -C_ Registrar of Vital Statistibs tiA
Date Issued \��jl'3 (signature)
District Number 5- Place ,.
;. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
', Date of Disposition 12/05/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) i (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
please print)
Signature Title Cei M11-701L
(over)
DOH-1555 (02/2004)