Spellacy, Ralph HEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
i Vital Records Section
Name First Middle Last Sex
Ralph Francis Spellacy Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/15/2016 83 War or Dates 1951-1954
Place of Death Hospital, Institution or
W City, 1:66icsimaixelic Plattsburgh Street Address CVPH Medical Center
1p Manner of Death 0 Natural Cause Accident O Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
its Claude Roland MD
Address
206 Cornelia St., Plattsburgh, NY 12901
Death Certificate Filed District Number Register Number
City, PIWPOPV4HAVe Plattsburgh 901
<< ®Burial Date Cemetery or Crematory
10/22/16 Pine View Cemetery
mi DEntombment Address
>'OCremation Queensbury, NY
Date Place Removed
gEl Removal and/or Held
and/or Address
F= Hold
C'f Date Point of
Q Transportation Shipment
L by Common Destination
Carrier
Disinterment Date Cemetery Address
g ElEl Renterment Date Cemetery Address
iggPermit Issued to Registration Number
>: Name of Funeral HomeSingleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
!i!i,iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address .
f
W
a` Permission is hereby granted to dispose of the human remains described above as indicated.
c -.
Date Issued 10/17/16 Registrar of Vital Statistics ------.. Lw.J
(signature)
District Number 901 Place City of Plattsburgh
I.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tr .
2
III Date of Disposition 1 0/22/1 6 Place of Disposition Pine View Cemetery,d QueenGbury NY
2 (a dress)
til Erie 1C 1
IX (section) (lot number) (grave number)
JOName of Se or Perso ' Charge of Premises Connie L. Goedert
2 (please print)
Dili Signature, Title Cemetery Super; ntPndent
(over)
DOH-1555 (02/2004)
SPELLACY Lot No. 1 C
Address Stitchman Towers Apt. 6 Jay St. glens calls NY 12801 Section No.
Owner Ralph & Carol Spellacy Plot Erie
Date January 11, 2008
Approx. 133 ._~y Superficial ft. @
Location Bounded on North by Vacant, on South by Road, on East by Vacant and West by Gnade
Corner Posts
Remarks Vw 792-0622 / 745-8302
Deed No. (and changes) 3527
Payment Record Paid in full 1/11/2008 ($2200.00)
•
Record of Interments V Ae A n T
-t-- l7A1DF
' Ralph Spellacv 19122/16 FB
0
41 X x
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1'
Form No. 01
SPELLACY
NAME Ralph Francis Spellacy Age: 83 II
Lot Owner: Ralph & Carol Spellacy
Lot# 1 C, Erie Grave# 1
Case: Concrete
Died: 1 0/1 5/2016 Interred: 1 0/2 2/1 6
Funeral Home: Singleton Sullivan Potter
Cemetery: Pine View