LaPoint, Raymond NEW YORK STATE DEPARTMENT OF HEALTH e L -# C I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Clifford LaPoint Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 11, 2013 82 War or Dates
Place of Death Hospital, institution or
City, Town or Village Johnsburg Street Address Adirondack Tri County HCF
Manner of Death rzfl
1'.
Natural Cause Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
L1 Daniel Way, M.D Dr.
Address
North Creek Health Ctr Warrensburg, NY
Death Certificate Filed District Number ^_--- Register lumber
City, Town or Village c�fo S �f
❑Burial Date Cemetery or Crematory
April 15, 2013 Pine View Crematorium
❑Entombment Address
it®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
t El Removal and/or Held
. and/or
Hold Address
Date Point of
W0 Transportation Shipment
= by Common Destination
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
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
le
Permission is hereby granted to dispose of the human/1 remainp o -described ab •s indicated.
nn lNj �
Date Issued / 02o/yegistrar of Vital Statistics R- & . C -Q- ..
Cl P--_�_ �—' / (signature)
District Number .5(g S r Place (C7 ZUr/ UJ `j,?S t`kJ 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1
Date of Disposition I1-P Place of Disposition .a(kW Cn► 0tsu.►
(address)
a (section) d
(lof number) c� (grave number)
Name of Sexton or Person i Charge of Premises l " '1n°�T
(ple se print)
Signature L Title cam L
g
(over)
DOH-1555 (02/2004)