Prime Jr, Raymond NEW YORK STATE DEPARTMENT OF HEALTH �1 /__S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Case Prime,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 13,2013 87 War or Dates World War II
I.. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ip Manner of Death a Natural Cause Accident Homicide Suicide 0 Undetermined Pending
Circumstances Investigation
G Medical Certifier Name Title
Frances C.Bollinger
Address
161 Carey Rd,Queensbury,NY 12804
Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5601 3 O
❑Burial Date Cemetery or Crematory
August 14,2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
E 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
1— Remains are Shipped, If Other than Above
2 Address
r
W
a Permission is hereby granted to dispose of the human remains described above as ipdicated.
Date issued c� `/W)1 +3 Registrar of Vital Statistics C 1'..A4 4 (,\.)
(signature)
District Number 5601 Place Glens Falls) AI'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition '))sJt! Place of Disposition ,{R,, Co.v,..) .. ,,.c4O, .,.
W (address)
Cl)
0 (section) -(tot number) (grave number)
ZName of Sexton or Person incharge of Premises �„ L— ,.S2Mr(14
W Tease print)
Signature 4 - Title CTt i-ARt
(over)
DOH-1555(02/2004)