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Stacy, Victor NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section "` Burial - Transit Permit Name First Middle Last Sex Victor E. Stacy Male Date of Death Age If Veteran of U.S. Armed Forces, 03/24/2015 73 yrs. War or Dates 1 961 -1 964 Place of Death Town of Hospital, Institution or City, Town or Village Ti ccnderoaa Street Address Moses-Ludington Hospital tii0 Manner of Death©Natural Cause ❑Accident 0 Homicide 0 Suicide ❑Undetermined ❑Pending ItiCircumstances Investigation al Medical Certifier Name Title 0 Todd R, Wa1dorf D_O_ Address 1019 Wicker Street Ticonderoga, NY 12883 Death Certificate Filed Town of district Number Register Number City, Town or Village Ticonderoga 1 564 ❑Burial Date Cemetery or Crematory ❑Entombment 03/26/2015 Pine View Crematory Address ®Cremation Queensbur , New York Place Removed Z Removal and/or Held 2 and/or ______________ H Hold O Date Point of % Transportation Shipment 0 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 iHE Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address tr III ` Permission is hereby granted to dispose of the human re ains described above as indicated. «i Date Issued 3/2 6/2 01 5 Registrar of Vital Statistics , '1 . Gl....e,� (signature) DO 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: 111 Date of Disposition307-ir Place of Disposition pi N✓L 1/ Oee--4-- ,c f W2 (address) Uil LC (section) l (lott umber) (grave number) Name of Sexton on in Charge of Premises J C. ii +�'�/ % of Z / 1 (please print) Signa44 �- Title 4-/4` 'A.,` (over) DOH-1555 (02/2004)