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Gray, Stacy Y. Public Health Law Sec. 4145(2b) 013162 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# #g3� NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle East Sex Stacy Y Gray Female Date of Death Age If Veteran of U.S.Armed Forces, 12/11/2019 39 Years War or Dates ZPlace of Death Hospital,Institution or W City,Town or Village Queensbury Town Street Address 12 Hewitt Road,Queensbury Town, New York 12804 p Mannerof Death W ❑ Natural Cause Accident Homicide Suicide Undetermined ©Pending V Circumstances Investigation C Medical Certifier Name Title Michael Sikirica MD Address 50 Broad Street,Waterford Town,New York 12188 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 187 Burial Date Cemetery,Crematory or Facility Name 12/18/2019 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed F and/or and/or Held N Hold Address RDate Point of to Transportation j5 by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F. Remains are Shipped,If Other than Above Address iL W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/16/2019 Registrar of Vital Statistics Caroline Mildegarde Barber(ECectronicalTySignec9 /signature/ District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition IZ III Ili Place of Disposition , / 4v` 2 (address/ W W (section) (tot number/ (grave number/ SName of Sexton or Person in Charge of Premises 4f,i Im L Smarr z J (p&ase print/ W Signature 1 Title DO H-1555(07/18)p 1 of 2