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Lafferty, Raymond • NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Raymond Lafferty Male Date of Death Age If Veteran of U.S.Armed Forces, 01/09/2022 59 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Hudson Falls Village Street Address 26 Juckett Drive, Hudson Falls Village, New York 12839 p Manner of Death © Natural Cause Accident ❑Homicide Suicide El Undetermined Pending U Circumstances Investigation LIJI 0 Medical Certifier Name Title Robert Lemieux Coroner Address 415 Lower Main Street, Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 1 Burial Date Cemetery,Crematory or Facility Name 01/18/2022 Pine View Crematorium Entombment Address ElCremation Queensbury Town, New York Donation Z• Removal Date Place Removed and/or and/or Held NH Hold Address 0 EL Date Point of Cl) ❑Transportation Ca 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 F- Remains are Shipped,If Other than Above 5 Address CC a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/14/2022 Registrar of Vital Statistics Cynthia,)Barn(EYectronica((ySigned) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 W Date of Disposition I/Id i 22 Place of Disposition (1,9-4- ,d,,` (address) W CC CC (section) 4 (lot number) (grave number) O �rtttLlll r! � ��tn.A1y I Name of Sexton or Person in Charge of Pre Z (plea print) W Signature Title C►rk+Ne DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 ,1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#