Lacey, Paul 'ti
it
NEW YORK STATE DEPARTMENT OF HEALTH '13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul A. Lacey Male
Date of Death Age If Veteran of U.S. Armed Forces,
2/1 1 /201 5 92 yrs. War or Dates No
F- Place of Death Town of Hospital, Institution or
City, Town or Village Street Address Heritage a1Co eas
Ui
9 Ticonderoga RPsic3Pntial Health Care
a Manner of Death 0 Natural Cause El Accident E Homicide El Suicide El Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
i< City, Town or Village Ticonderoga 1 5f 4 9
['Burial Date Cemetery or Crematory
QEntombment 2/12/2015 Pine View Crematory
Address
[Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
2 and/or
F- Address
CO
Hold
0 Date Point of
gL Q Transportation Shipment
C by Common Destination
Carrier
Q 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
IX
Ili
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/1 2/201 5 Registrar of Vital Statistics I}')
(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:
IL/• Date of Disposition 21t311c Place of Disposition L. CriNfeto
s' " (address)
tji
0
is (section) / lot number) (grave number)
Ct• Name of Sexton or Person Char a of Premises L
Z (MOase print)
) Signature Title �1W""
(over)
DOH-1555 (02/2004)