Lockhart, Raymond Gene I e ‘,0
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NEW YORK STATE DEPARTMENT OF HEALTH ' Burial - Transit Permit
Bureau of Vital Records •
Name First Middle Last Sex
Raymond Gene Lockhart Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/14/2023 87 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
IU
p Manner of Death EI Natural Cause Accident Li Homicide Suicide ❑Undetermined .Pending
Circumstances Investigation
0 Medical Certifier Name Title
Jeremy Di Bari MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Fails District Number Register Number
City,Town or Village 5601 26
BurialE
Date Cemetery,Crematory or Facility Name
01/17/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZZ❑Removal Date Place Removed
and/or and/or Held
t- Hold Address
N
0
O. Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
EDisinterment 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
H Remains are Shipped,If Other than Above
2 Address
CC
NA
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/17/2023 Registrar of Vital Statistics Megan Wolin(ECectronicaltySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition ,1 to 173 Place of Disposition —i ? IL
Z(---
ILI
2 (address)
W
N
CC (section) (lot number) (grave number)
/
8 ::::::: °
or Person in Charge of Pre ' Title ' "'front-T0�
DOH-1555 07/18)pi of 2
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I6bsO
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named o,n burial permit
Official Funeral Directors Reg.or License# •