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St. John, Raymond Victor ; �� ) cz3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Raymond Victor St.John Male Date of Death Age If Veteran of U.S.Armed Forces, 06/23/2021 86 Years War or Dates 1954-1958 H Place of Death Hospital,Institution or Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing LIJ h of Manner Death © Natural Cause El Accident Homicide Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title CI Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 53 Burial Date Cemetery,Crematory or Facility Name 06/25/2021 Pine View Crematorium El Entombment Address lCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held Hold Address N 0 d Date I Point of co ❑Transportation —II p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/25/2021 Registrar of Vital Statistics Jenny Linda M Martelie(ECectronicaCCy Signed) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- Z Date of Disposition d 0-?Ai( Place of Disposition aQ West.) iiii-GIV4hLLJ 2 (address W N CC (section) (lot nunber)J (grave number) O Name of Sexton or Person in Charge of Premise Y��.r �� (please print) W Signature IL` Title e per�i+►r DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01.4891 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#