Roulier, Raymond WIT
NEW YORK STATE DEPARTMENT OF HEALTH M �L Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Raymond J. Roulier Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 13, 2015 95 War or Dates World War II
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre
wp Manner of Death I XI Natural Cause Accident ❑Homicide I Suicide n Undetermined n Pending
Circumstances Investigation
W' Medical Certifier Name Title
G Suzanne Blood MD
Address
Queensbury,NY
Death Certificate Filed 5657 District Numbe5657 Mer Number
City, Town or Village
❑Burial Date Cemetery or Crematory
February 17, 2015 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
aAddress
W
Permission is herebyI A grantedl to dispose of the human e ains describedd above as indicated.
Date Issuec�E 1 k J Registrar of Vital Statistics _ q. j8/1,(�
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W Date of Disposition Z(IJIc Place of Disposition 1zUu 6r-'iofr-
2 (address)
W
O (section) Ar, ..(lot numbw) (grave number)
p Name of Sexton or Person in Charge of Premises
Zp/ease print)
W Title CIF.A"efk,
Signature
(over)
DOH-1555(02/2004)