Raymond, Donald Ivan ( F) b.
NEW YORK STATE DEPARTMENT OF HEALTH \., •
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald Ivan Raymond Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/06/2022 33 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Malone Village Street Address 44.51.14N 74.16.52W Housing Authority,Malone Village,New York 12953
IJJ
p Manner of Death 0 Natural Cause Accident ❑X Homicide El Suicide FlUndetermined n Pending
uJ
C.) Circumstances Investigation
C Medical Certifier Name Title
Brian Langdon Coroner
Address
4 Porter Avenue,Malone Village,New York 12953
Death Certificate Filed Village Of Malone District Number Register Number
City,Town or Village 1624 74
Burial Date Cemetery,Crematory or Facility Name
10/11/2022 Pine View Crematory
Entombment Address
-
Cremation Queensbury Town,New York
ElDonation
0❑Removal Date Place Removed
and/or and/or Held
F Hold Address
N
0
O. Date Point of
N OTransportation
`p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment
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
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/11/2022 Registrar of Vital Statistics Wf6afka L Scaccia(ECectronicaffySigned)
(signature)
District Number 1624 Place Village Of Malone
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: //
W pkte of Disposition f�ift 1t Place of Disposition
�-P�—
2 (addres
W
iCC (section) (lot n ber) (grave number)
gName of Sexton or Person in Cha emises 4^b4pL
z u (please print)
fW /
/Signature Title ! ek4114114
DOH-1555(07/18)p 1 of 2
1 , .
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ; delivered on ! , 20
Pine View Cemetery Representing the funeral home name l'on burial permit
Official Funeral Directors Reg.or License# - .