Humphreys, Raymond Edward NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Raymond Edward Humphreys Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/16/2021 72 Years War or Dates 1968-1972
1— Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address Albany Medical Center Hospital
p Manner of Death ❑X Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined 1=I Pending
W Circumstances Investigation
WMedical Certifier Name Title
Brett Friedler DO
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 2042
❑Burial Date Cemetery,Crematory or Facility Name
08/18/2021 Pine View Crematory
0 Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
ZO ❑Removal Date Place Removed
and/or and/or Held
F Hold Address
O
C- Date Point of
tt) ❑Transportation
p by Common Shipment
Carrier Destination
0 Disinterment
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
a Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/17/2021 Registrar of Vital Statistics Danidk Sgz&spre(i&'ctronicadj,Signed)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition $I art( Place of Disposition e nA.V.—
(address)
ILL
CC (section) � (lot number) (grave number)
GName of Sexton or Person in Charge of remises llliii n '�.{�r
(pletse print
tU Signature Title L i* 14 V(
DOH-1555(07/18)p 1 of 2
1 ni .(-1c ,-)
Public Health Law Sec. 4145(2b)
I
Receipt
, ', .
Human remains of + � � k ,,
f � , ` - delivered on ' - , 20 J..1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# I .1