Holmes, Raymond NEW YORK STATE DEPARTMENT OF HEALTH 4ir 126.,
Vital Records Section Burial - Transit Permit
i
VI Name First Middle Last Sex
Raymond Holmes Male
Date of Death Age If Veteran of U.S. Armed Forces,
• x 11/30/2018 59 Years War or Dates;. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ci Manner of Death g Natural Cause Accident El Homicide D Suicide n Undetermined Pending
Circumstances Investigation
N _
Medical Certifier Name Title
David Cunningham MD
Address
100 Park St,Glens Falls,New York 12801
y Death Certificate Filed District Number Register Number
'- Ci: ty, Town or Village Glens Falls 5601 566
❑Burial Date Cemetery or Crematory
12/04/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
rl iDate Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
[:Transportation Shipment
by Common Destination
• Carrier
Q Disinterment
Date Cemetery Address
r;y
Reinterment
Date Cemetery Address
'• Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
,x, Address
• 11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/03/2018 Registrar of Vital Statistics Ro6ertA Curtis(ECectronicaCCy Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition a-,1,-i g Place of Disposition i h k, V►`w Grt,I'C9 iC C y
(address)
g
(section) (lot number) (grave number)
ec-
Name of Sexton or Person in Charge of Premises �i f mc,7 S ;C c
(please print)
Signature „ Title Gfv a"1-C,}t'r
(over)
DOH-1555 (02/2004)