Olcott, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond T,, 0lcott Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/27/2014 75 yrs_ War or Dates No_
1-- Place of Death Town of Hospital, Institution or
Z City, Town or Village Street Address Heritage Commons
g
114 Ticonderoga Residential Hea1thr-are
Manner of Death 0 Natural Cause 0 Accident Homicide Suicide 0 Undetermined Pending
W Circumstances Investigation
Lij Medical Certifier Name Title
Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village • • . ... .. . 1964 13
❑Burial Date Cemetery or Crematory
['Entombment pine View Crematory
Address
kECremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
F- Hold
A
C Date Point of
EL
❑Transportation Shipment
Et by Common Destination
Hii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1r
lL!
P' Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued 2/2 8/2 01 4 Registrar of Vital Statistics P7 ` /-Gr-(G-7
(signature)
ildi District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p Place of Disposition -�ntUir,.1 -,Mori,_.l� Date of Disposition 3 1�iy p
(address)
at
t)
ilk (section) (lot number)/- (grave number)
Sa Name of Sexton or Person . Charge f Premises /LI e r
2 ( lease print)
114
Signature Title CrAQ
(over)
DOH-1555 (02/2004)