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Sergio, Stacie P.
P /iI NEW YORKSTATE DEPARTMENT OF HEALTH ,, ' Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Stacie P.Sergio Female Date of Death Age If Veteran of U.S.Armed Forces, 3, 02/02/2021 58 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Warrensburg Town Street Address 6 Hoffman Drive,Warrensburg Town, New York 12885 111 1 O Manner of Death ©Natural Cause ❑Accident ElHomicide ❑Suicide ❑Undetermined ID Pending Circumstances Investigation G Medical Certifier Name Title -01 Michael Bell MD Address 9 Carey Road,Queensbury Town,New York 12804 ,ti, Death`Certificate Filed District Number Register Number City,Town or Village Warrensburg 5660 3 Burial Date Cemetery,Crematory or Facility Name 02/06/2021 Pine View Crematory 1 , Li Entombment Address li. uu Cremation Queensbury Town,New York _ El Donation 2 Date Place Removed O Removal and/or and/or Held w Hold Address 0 Q Date Point of CO ❑Transportation Q by Common Shipment Carrier Destination ' Date Cemetery Address r.. Li Disinterment ;" ❑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 i= Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. _ Date Issued 02/05/2021 Registrar of Vital Statistics 'Pamela 11 LCoy r('Ehctronica1TySigned) is (signature) District Number 5660 Place Warrensburg, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F W Date of Disposition —6_a p2( Place of Disposition �` ,�z' fit, �fefn 6�f0 2 (address) W Cl) CC (section) �/ y� (lot number) �,,,f, (grave number) ciName of Sexton or Person in Charg of Premises ''�f�7 7G/✓1J W `'Y se print) l Ili Signature ` / Title dy DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) f \ t . 014 J 2 a Receipt i delivered on , 20 Human remains of ' r. Pine View Cemetery Representing the funeral home named on burial permit 4 Official Funeral Directors Reg.or License# I i