Belleville, Raymond (,77
NEW YORK STATE DEPARTMENT OF HEALTH i '`Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Belleville Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/11/2013 71 years War or Dates
}- Place of Death Hospital, Institution or
TowR*)002 XX Glens Falls Street Address glens falls, n y 12801
W Manner of Death f�tural Cause ❑Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
narci A Gaintti-grubbs M D
Address
102 Park St Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
Cit Tows )(il g(XX Glens Falls 5601 471
0Burial Date Cemetery or Crematory
■ ntombment 11/12/2013 Pine View Crematory
Address
1. -mation Queensbury. NY
Date Place Removed
Z❑Removal and/or Held
and/or
Address
Cl) Hold
0 Date Point of
rl to Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870 /dM Si- q
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
tt
ILI
Permission is hereby granted to dispose of the human remains described above as indicated.
AiH Date Issued 11/12/2013 Registrar of Vital Statistics (,1.)
(signatur
District Number Place
5601 Glens Falls / "y /ag0/
`" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI
/N� C,,n
Date of Disposition �� Place of Disposition Ry� ��jL� ,"G ��
(address
in
te
CC (section) �� /191,luy�►ber) (grave number)
ci Name of Sexton sr on . rge of Premises .E'>>'I el
lZi (please rint)
Signatur Title ( i4,i G- ;
(over)
DOH-1555 (02/2004)