Rayno, Frank John 1 yt/g
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Frank John Rayno Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/26/2021 70 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address 48 Perkins Drive, Fort Edward Town, New York 12828
LU
W Manner of Death ❑X Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W• Medical Certifier Name Title
Q
William Parker MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 27
Burial Date Cemetery,Crematory or Facility Name
05/28/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
ElDonation
❑ Removal Date Place Removed
and/or and/or Held
i- Hold Address
0
O. Date Point of
Cl) LI Transportation
El by Common Shipment
Carrier Destination
IEIDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
2 Address
Q
III
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/28/2021 Registrar of Vital Statistics .AimeeL Maloney gYectronicallySrgned4
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
INZ/f—L
Z Date of Disposition .-II7$i 14 Place of Disposition ��
W
(address)
W
CA
(section) /!ot number) (grave number)
O Name of Sexton or Person in Charge of emises r iq �' "'df �
Z (please rint)
W Signature Title ` �
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 014E 16
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#