Stacy, Joseph "14 QV
NEW YORK STATE DEPARTMENT OF HEAL ` /
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph Peter Stacy Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 21 , 2014 46 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address 19 Battery Street
ci Manner of Death®Natural Cause ❑Accident El Homicide El Suicide El Undetermined ❑Pending
IL/ Circumstances Investigation
:L Medical Certifier Name Title
a Eric Pillemer M_n_
Address
Glens Falls Hospital, Glens Falls, NY 12301
Death Certificate Filed Town of District Number Register Number
City, Town or Village rill cnnderoga 1 564
; El Burial Date Cemetery or Crematory
❑Entombment July 23, 2.01 4 Pine View Crematory
Address
remation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
2 and/or
Address
F
Hold
tel
O Date Point of
CL cn Transportation Shipment
f by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
F„ Remains are Shipped, If Other than Above
• Address
fr
It
' Permission is hereby granted to dispose of the human r ain describe a ov a indicated.
Date Issued 0 7/2 3/2 01 4 Registrar of Vital Statistics rkJUJY'lpiX0(__
(si natlre)
District Number 1 564 Place Town of Tico roga
;: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
la Date of Disposition 7 it Iy Place of Disposition tVA-I Crc. aru—
(address)
to
Mt
CC (section) J (lot number) rs (grave number)
Ci Name of Sexton or Person in Charge of Premises
(pl ase print)
ILI Signature Title
C 2 )AIrt
(over)
DOH-1555 (02/2004)