StPierre, Ralph NEW YORK STATE DEPARTMENT OF HEALTH 1 L
Burial - fansit Permit
Vital Records Section
"" Name First Middle Last Sex
Ralph St. Pierre Male
.H' Date of Death Age If Veteran of U.S. Armed Forces,
May 5, 2013 95 War or Dates
wPlace of Death Hospital, Institution or
City, Town or Village Street Address The Pines at Glens Falls
Manner of Death j Natural Cause 0 Accident E Homicide 0 Suicide 0 Undetermined 0 Pending
1.11 Circumstances Investigation
14)
W Medical Certifier Name Title
Suzanne Rayeski, M.D. Dr.
' Address
-:. 3767 Main Street Warrensburg, NY
" Death Certificate Filed District Number Register Number
City, Town or Village 5601 ZG 2-
0 Burial Date Cemetery or Crematory
May 9, 2013 Pine View Crematorium
, 0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
,t,ri Removal and/or Held
and/or Address
Hold ADIRONDACK-BURLINGTON
Date Point of L
;C i. I I Transportation Shipment
14 by Common Destination
'r Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
,., Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
y` Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
T Name of Funeral Firm Making Disposition or to Whom
t5 Remains are Shipped, If Other than Above
Address
04
ll=
, Permission is hereby granted to dispose of the human remains d crib d ov ' dicated.
Date Issued QSOil20/3 Registrar of Vital Statistics � � •
(signature)
District Number 5601 Place �G //iP- . 6�, A'>'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'Fit'
f p
jj, Date of Disposition _ 3 .- ? .L (7 '�� p �10'l Place of Disposition , Ga �c act.
2 (address)
Lioi
is (section) ` (lot number) (grave number)
Name of Sexton or P rson in Ch rge of Premises '/�+ Sitti
(please print)
Lik Signature Title CU M 77JL -
(over)
DOH-1555 (02/2004)