Bush Jr, Raymond rill
NEW YORK STATE DEPARTMENT OF HEALTH i `-
Vital Records Section � Burial - Transit Permit
Name First Middle Last Sex
Raymond Paul Bust Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
1 2-7-1 3 72 War or Dates Yes, 1959-1962
Place of Death • Hospital, Institution or
City Of Glens Falls P Glens Falls Hospital
Z City, Town or Village Street Address
0 Manner of Death❑x Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
4 Sean BainMD
102 Park St.AV��lens Falls, New York 12803
Death Certificate Filed city Qf District Nite5 i Re umber
City, Town or Village Glens toalls
-. ['Burial ' Date - Cemetery or Crematory
Dec. 9, 2013 Pine View Crematory
❑Entombment Address
EICremation 21 Quaker Road Queensbury, New York 12804
Date Place Removed
Z ri Removal and/or Held
2Ljand/or Address
F= Hold
Cif
0 Date Point of
ili❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to M. B. Kilmer Funeral Home Registration Number
Name of Funeral Home 01078
Address
136 Main St. South Glens Falls, New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILu
Permission is hereby granted to dispose of the human re ains de cribed ab a as indica d.
iq Date Issued 1 2-9-1 3 Registrar of Vital Statistics �1__,_,0`�;
(signature)
District Number .56
0/ Place City Of Glens F lls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1.11 Date of Disposition la_io-13 Place of Disposition g.t 0N0 C irArf...
2 (address)
W
Vit
(section) lot number) (grave number)
Ci Name of Sexton or Person i Charge of Premises l h,t� 31mk6t
A (plea print)
. Signature �Q Ml�i01t'
� Title C
1
(over)
DOH-1555 (02/2004)