Stacy, Judith ' 739
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ., Burial - Transit Permit
Name First Middle Last Sex
Judith Ann Stacy Female
'=> Date of Death • Age If Veteran of U.S. Armed Forces,
:s' 10/03/2017 75 yrs. War or Dates No
i Place of Death Town of Hospital, Institution or Heritage Commons
Z. City, Town or Village Ticonderoga Street Address Residential Health Care
13 Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
IU
Circumstances Investigation
Medical Certifier Name Title
0 Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register N tuber
City, Town or Village Ticonderoga 1 564 /
ia 0 Burial Date Cemetery or Crematory
10/05/2017 Pine View Crematory
W ['Entombment Address
❑X Cremation Queensbury, New York _
Date Place Removed •
g.❑Removal and/or Held _
3 and/or Address
t
Hold
0 Date Point of
si❑Transportation Shipment
II by Common Destination
Carrier
El Date Cemetery Address
OEi El Reinterment Date Cemetery Address
ii. Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
iN Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re i s describe ov a indicated.
lini
Date Issued 10/5/201 7 Registrar of Vital Statistics
(si nat e)
>' District Number 1 564 Place Town of Ticonderoga
.ii ,> I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1p.5-../7 Place of DispositionPj31.L U,`tc) L re_-ree,
(address
ji
in
it (section) t (lot number) (grave number)
Name of Sexton or P s . Charge of Premises J lit,,ez '64-eat
(please print)
Signature Title t-,'2 bri- o-C
(over)
DOH-1555 (02/2004)