Irish, Raymond •
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
. Name First Middle Last Sex
tt,} Raymond H Irish Male
Date of Death Age If Veteran of U.S. Armed Forces,
EtMarch 21, 2017 82 War or Dates
�ry
LPlace of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
Manner of Death M
inj Natural Cause 0 Accident ED Homicide Suicide 0 Undetermined Pending
0. Circumstances Investigation
All, Medical Certifier Name Title
-: Daniel C Larson M.D.,
. Address
Et 9 Carey Road Queensbury, NY 12804
XDeath Certificate Filed Dis h umber Regis umber
City, Town or Village
`®Burial Date Cemetery or Crematory
March 31, 2017 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold Pine View Cemetery
Date Point of
it Ei Transportation Shipment
by Common Destination
CC Carrier
EN
Disinterment Date Cemetery Address
_dam
Reinterment Date Cemetery Address
E Permit Issued to Registration Number
NE
Name of Funeral Home Carleton Funeral Home, Inc. 00281
EN
Et Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
* N• ame of Funeral Firm Making Disposition or to Whom
,. Remains are Shipped, If Other than Above
A• ddress
IS
. : Permission is ereb granted to dispose of the hum = -ins described e as in ated.
E Date Issued Registrar of Vital Statist
Aft ------ ei___, (signature)
itA District Numbe Place
_lAdri
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E-:
W Date of Disposition 03/31/2017 Place of Disposition Quaker Rd. Queensbury,NY 12804
c'
(address)
59 A Erie
(see ) /(lot number) (grave number)
rt Name of ton or Person in Charge of Premises 1 �iL � jf��
(ple rint) _
Signatur �i2"`'"n Title"=' 12—r-Nr
(over)
DOH-1555 (02/2004)