Davignon, Raymond Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Raymond Davlgnon
were cremated on July 13 20 22 at the Pine View
(Month) (Day)
Crematorium, Queensbury, New York, and these are the cremated remains of said body.
Date of Death July , 8 20 22 Age 87
(Month) (Day)
Funeral Home Baker Funer Home Registered No. 546
(Authorized Signature)
if
5 Itt.
NEW YORKSTATE DEPARTMENT OF HEALTH
ELF) r. Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Raymond Kenneth Davignon Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/08/2022 87 Years War or Dates 1955-1959
Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address 15 Shippey Street,Glens Falls,New York 12801
p Manner of Death ❑X Natural Cause Accident El HomicideSuicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
a Aimee Mcmaster Nurse Practitioner,Acute Care
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 357
EiBurial Date Cemetery,Crematory or Facility Name
07/11/2022 Pine View Crematory
Entombment Address
®Cremation Queensbury Town,New York
▪Donation
p Removal Date Place Removed
and/or and/or Held _
H Hold Address
N
0
O. Date Point of
d1❑Transportation
5 by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
LU
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/11/2022 Registrar of Vital Statistics MeganTro1n(E(ectronicalTySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ')1 a i t2 Place of Disposition ,xtj /4dr.--_,
2 (address)
W -
Q (section) A (lot number) (grave number)
8 Name of Sexton or Person in Charge of P mises #r.•1 i..— *WO
Z ( ease print/ �+ ni
W Signature r4KTitle c ,"�
DOH-1555(07/18)p 1 of 2
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# F !
DAVIGNON
NAME Raymond Davignon Age: 87
Lot Owner: Orletta Davignon
Lot# Mohican 66A Grave# 2B
Case: Urn
Died: 7 .8.2 2 Interred: 7, 18.2 2
Funeral Home: Baker FH
Cemetery: Pine View
DAVIGNON 1.63
Lot No. 6 6-A
address 138 Broad St . , Glens Falls . NY 12801 Section No.
)wner Orletta Davignon Plot Mohican
)ate 2/19/96
Approx. 67 Superficial ft. @
,ocation Bounded cm North by Vacant. South by Vacant . East by Vacant .
West by Vacant .
corner Posts
Zemarks
)eed No. (and changes) 2726
'ayment Record Paid in Full 2/17/96 ( $7 0 0 . 0 0 )
tecord of Interments
Kenneth L. Davignon 2/17/96
Orletta B. Davignon 12/5/01 ✓
. .�.as A
A
X
N
N
T
7
Form No. 01