Matteson, Sr. Raymond NEW YORK STATE DEPARTMENT OF HEALTH 4 L31
Vital Records Section
Burial - Transit Permit
. Name First Middle Last Sex
Raymond Milford Matteson Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 1, 2012 76 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hebron Street Address 12 Matteson Way
`. Manner of Death1=1 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
x Medical Certifier Name Title
Daniel P. Garfinkel, Dr.
Address
213 Main St. Salem, NY 12865
Death Certificate Filed District Number Register Number
- : City, Town or Village Hebron
1 .0 Burial Date Cemetery or Crematory
May 7, 2012 Pine View Crematory
il❑Entombment
Address
®Cremation 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
z'. ❑ Disinterment
Date Cemetery Address
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
Address
123 Main St., Argyle NY 12809
? ...; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission iss hereby" granted to dispose of the human rem desc 'be s ove�icatpd.
Date Issued-vr1, ,1 ��z Registrar of Vital Statistics ( . P-7
(signature) U
District Number 676 0 Place Ne 6Ro to
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/07/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numper) (grave number)
Name of Sexton or Per on in Char a of Premises �r+st t"'tt
(please print)
Signature Title M at
i
(over)
DOH-1555(02/2004)