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Lacey, Kathryn # 2110 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Kathryn Musso Lacey Female Date of Death Age If Veteran of U.S. Armed Forces, 03/20/2018 94 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Elizabethtown Town Street Address Elizabethtown Community Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined El❑Pending Circumstances Investigation iti Medical Certifier Name Title Mary Halloran MD Address ; 75 Park Street PO Box 277,Elizabethtown Town,New York 12932 0 Death Certificate Filed District Number Register Number - City, Town or Village Elizabethtown 1552 30 El Burial Date Cemetery or Crematory 03/22/2018 Pine View Crematory El Entombment Address ®Cremation Queensbury, New York Date Place Removed ,=❑Removal and/or Held and/or Address t/l Hold Date Point of ❑Transportation Shipment by Common Destination '' Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number 1 Name of Funeral Home Wilcox&Regan 01821 r Address 11 Algonkin St,Ticonderoga,New York 12883 ,, Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/22/2018 Registrar of Vital Statistics Janet E Cross(ECectronica1Ty Signed) Ati (signature) District Number Place ,,, 1552 Elizabethtown, New York ,ti I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ;"- Date of Disposition 31L3/1$ Place of Disposition emU,. 1.-(aess) 0 (section) I (lot num r)i (grave number) Name of Sexton or Person in Charge of Premises `��dp�, Js'� ( (please print) Signature Gi .1.- Title tOrline7 (over) DOH-1555 (02/2004)