Tougas, Ray NEW YORK STATE DEPARTMENT OF HEALTH r ) --/ 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
4 Ray Leroy'.. Tougas Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 19, 2014 93 War or Dates World War II
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Deathlvl
izu Natural Cause 0 Accident D Homicide El Suicide 0 Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Na a Title
CI
0 (1acj_rht r 1 . O lS1�� nt>
Address J
/oc> /max k s 4. '/c r s ,c l(., )us( )l 5 c i
Death Certificate Filed bistrict Number Re mber
City, Town or Village C[ens ..,(1 r)�'
0 Burial Date Cemetery or Crematory
)Z/ 2 /Z Oi y Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensb ry,NY 12804
Date I Place Removed
Removal and/or Held
and/or Address
E Hold
0) Date Point of
0 Transportation Shipment
by Common Destination
O, Carrier
Disinterment Date Cemetery Address
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
g' Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
ff Address
W+
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i Z,j Z,z) i y Registrar of Vital Statistics U3 A AW
(signs ure)
District Number 5 L6l Place 6is".Sn 5 / 0
I—
, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ; 7./23)t4 Place of Disposition Quaker Road Queensbury,NY 12804
Burial on (address)
CO-
it Tfilige,Lot in flot number (grave number)
0 Sec 4
Name of Sexton or Perscln in Char e of Premises dr. A.wriPi
Z (please print)
LP Signature Title Clvo roan.
(over)
DOH-1555(02/2004)