Wright, Raymond i .72�f
NEW YORK STATE DEPARTMENT OF HEALTH ` '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Charles Wright Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 16, 2014 76 War or Dates
F Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 10 Ohio Avenue
Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide n Undetermined ❑ Pending
LU
CO Circumstances Investigation
W Medical Certifier Name Title W
John Lukaszewicz, Dr.
Address
84 Broad Street Glens Falls, NY 12801
Death Certificate Filed Dis rict Number Re aster Number
may, Town or 41 Queensbury ¶(.off 1 I
❑Burial Date Cemetery or Crematory
November 25, 2014 Pine View Crematorium
❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
I I
O and/or Address
F. Hold
Tr
W Date Point of
(Ly n Transportation Shipment
CO by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
- Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
'r Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
• Address
ix
L Permission is hereb granted to dispose of the human remains described above as indicated.
Date Issued ( 1 Vi t Registrar of Vita! Statistics ic____, . ( ' ?�
(signature)
District NumbeS-(yc—Th Place d �, .� Ca•
. I certify that the remains of the decedent identified above were disposed of i ccord nce with this permit on:
W Date of Disposition 11/25/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W''
✓ (section) /f (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises C-kr's(upL— So°.-cbt
Z (p'ease print)
Signature A` 7. Title Olt el}f0S
(over)
DOH-1555 (02/2004)