Lacy, Sandra NEW YORK STATE DEPARTMENT OF HEALTH-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sandra Lee Lacy Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/01/2018 71 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Johnsburg Town Street Address Elderwood at North Creek
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City, Town or Village North Creek 5655 26
❑Burial Date Cemetery or Crematory
10/03/2018 Pine View Crematory
El Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal
and/or and/or Held
Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
�a w'
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/02/2018 Registrar of Vital Statistics KgthkenC.Lorah(cE(ectronicalTySigned)
(signature)
tert District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ( )IIi, Place of Disposition 1%)h,� c m-.,
(address)
(section) (lot N.mber) (grave number)
Name of Sexton or Person in Charge of Premises {�'+� 3 0�•�1`
(please pr t)
Signature Title CaPrittfig.
(over)
DOH-1555 (02/2004)