Haynes, Raymond NEW YORK STATE DEPARTMENT OF HEALTH 11 II lN)
Vital Records Section Burial - Transit Permit
tit. Name First Midd . Last Sex
4.
44 Raymond Harold Haynes Male
Date of Death Age If Veteran of U.S. Armed Forces,
1- 7/14/2013 63 War or Dates
Z Place of Death Hospital, Institution or
W City,30000:131VAINK Glens Falls Street Address Glens Falls Hosptial
0 Manner of Death Natural Cause ❑Accident n Homicide nSuicide O Undetermined p Pending
W Circumstances Investigation
0 Medical Certifier Name Title
lli Q Amy Hogan-Moulton MD
0 Address
Rrcjad Street, GLens Falls NY 1 2801
Death Certificate Filed District Number �� RegisterAl&City,Xl� Glens Falls 56
Date Cemetery or Crematory
❑ Burial 7/17/2013 Pine View Crematoirum
Address
®Cremation Queensbury, NY
2 Date Place Removed
0 0 Removal and/or Held
- and/or Address
Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
0 Carrier
Date Cemetery Address
a ❑ Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc., 00281
Address
68 Main St., Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
ii Remains are Shipped, If Other than Above
w Address
I
Permission is hereb granted to dispose of the human remains de ribe a ve seated.
Date Issued 02 /7 �a Registrar of Vital Statistics ?'� /i
i g
(signature)
District Number 560/ Place --7,/ /L
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition Place of Disposition
2 (address)
W
0
t (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises
2 (please print)
Signature Title