Guyette, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section 4 Burial - Transit Permit
Name First Middle Last Sex
Raymond G. Guyette Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 23, 2013 65 War or Dates Navy
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death
X Natural Cause Accident E Homicide E Suicide
Name Title Undetermined n Pending
Circumstances Investigation
"� Medical1 Certifier
{ John Stoutenberg,MD
Address
> ' Glens Falls,NY 12801
fl Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 //
El Burial Date Cemetery or Crematory
❑Entombment March 26, 2013 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
z C Removal and/or Held
and/or Address
H Hold
N
aDate Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
111
Reinterment Date Cemetery Address
Permit Issued to Registration Number
=', Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
`r Name of Funeral Firm Making Disposition or to Whom
, Remains are Shipped, If Other than Above
Address
tt
t;t,a Permission is hereby granted to dispose of the human iemains describe bove as in. >..
Date Issued Registrar of Vital Statistics a, , _ 4/--(
( ignature) \
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3•fl-‘3 Place of Disposition ZV,,t,,,, �ry r..ttt,vN-
Z (address)
W
Cl)
re (section) lot number) ( (grave number)
pName of Sexton or Person in Charge of Premises l l f n„p�}
Z i(please print)
W Signature Title Ca it)AID(Z
(over)
DOH-1555(02/2004)