Stacy, Christopher i. it n 370
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Christopher Lee Stacy Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 16, 2015 44 yrs. War or Dates No
• Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
W Manner of Death❑X Natural Cause El Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
ta
tu Medical Certifier Name Title
O C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti r•nnrIc rnga 1 564 29
❑Burial Date Cemetery or Crematory
<;❑Entombment 5/20/2019 Pine view Crematory
Address
cremation Oueensbury, New York
Date Place Removed
2 in Removal and/or Held
.., and/or Address
i= Hold
ffi.0 Date Point of
CI' ❑Transportation Shipment
d by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;Z Address
Ui
` Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 5/1 9/2 01 5 Registrar of Vital Statistics \ 279 . Q 2 ,
(signature)
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI N_
• Date of Disposition 51 ZLJJ� Place of Disposition /Q['� .^to,.^
._,
2 (address)
Ili
to
tz (section) A(lot cumber) (grave number)
Name of Sexton or Person in Char a of Premises Cyr/•r ,Sire
.ram (plbase print)
• Signature X Title ac tt '1.
(over)
DOH-1555 (02/2004)