Stacey, Robert e R
NEW YORK STATE DEPARTMENT OF HEALTH # -7(0o
Vital Records Section Burial - Transit Permit
Name Firsi$obert Middle A. Lacey Sex Male
DaitAfllt Agg1 years If Veteran of U.S. Armed Forces,
War or Dates
I Place 96But Hospital, Institution r
XXX Saratoga Springs P �v�Ellis Avenue, #C7, Saratoga Springs, N Y
Ott City, Town or it age Street Address
Manner of DeathL. Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
W Medical Certifier N T
� �aevid Mastrianni, Md glep
Adgeare Lane, #300, Saratoga Springs, N Y
Death *A *b Saratoga Springs Distrifelumber Regylter Number
City, Town or Village
[]Burial Date 12/13/2013 Cerr &%VdP4 q ry
Entombment Addr
Haeensbury N Y
Cremation
Date Place Removed
Z❑Removal and/or Held
..� and/or Address
H Hold
tel
O Date Point of
aQ Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to M. B. Kilmer Funeral Home Regn Number
Name of Funeral Home
Addreals36 Main Street, South Glens Falls, New York
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
fr.
Ef
C' Permission is hereby granted to dispose of the human rem or' ed abpl indicat d.
12/13/2013 C`
Date Issued Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E ` �
tu Date of Disposition 1.1-Ib'13 Place of Disposition -�n L. tv ap4tg1L..
2 (address)
tti
CC (section) / lot number) (grave number)
CI Name of Sexton or Person i Charge f Premises ` n ikiit r codile
Z A (plea#e print)
Signature Title ChE vVe
(over)
DOH-1555 (02/2004)