Raymond, Priscilla Ann NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Priscilla Ann Raymond Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/05/2022 73 Years War or Dates
t.. Place of Death Hospital,Institution or
WCity,Town or Village Ticonderoga Town Street Address Elizabethtown Community Hospital Moses Ludington
p Manner of Death Fiji Natural Cause []Accident []Homicide []Suicide [-Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Kellie Valentine Coroner
Address
PO Box 132, Elizabethtown Town, New York 12932
Death Certificate Filed Town Of Ticonderoga District Number Register Number
City,Town or Village 1564 25
Burial Date Cemetery,Crematory or Facility Name
06/0 /2022 Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
Donation
d El Removal Date Place Removed
and/or and/or Held
to Hold Address
0
O. Date Point of
N[]Transportation Shipment
by Common
Carrier Destination
Date Cemetery Address
[]Disinterment
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
5. Address
W
et" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/08/2022 Registrar of Vital Statistics Tonya 51?'Thompson('ECectronicalrySigned)
(signature)
District Number 1564 Place Town Of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition (P/ti IZL Place of Disposition
(address)
W
CCCC (section) (lot numbed (grave number)
Name of Sexton or Person in Charge of Premises n' `'—' M It
lease print
w ` �'�ti
Signature Title
DOH-1555(o7/18)p tof 2
... ,' 1 577 4
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial,permit
Official Funeral Directors Reg.or License#