Lee, Stacey Jeanne l'y
NEWYORKSTATE DEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle last Sex
Stacey Jeanne Lee Female
Date of Death Age If Veteran of U.S.Armed Forces,
r
0228/2022 48 Years War or Dates
H Place of Death Hospital.Institution or
Z City,Town or Village Ballston Spa Village Street Address Gateway House
I+ Mannerof Death Ei Natural Cause EAccident Ej Homicide' Suicide Undetermined ❑Pending
W0 Circumstances Investigation
WW Medical Certifier Name Title
CI John Deknonte MD
Address
3 Care Lane,Saratoga Springs,New York 12866
Death Certificate Filed Verge of Ballston� District Number Register Number
Cit E,Town or Village 4520
Burial Date Cemetery,Crematory or Facility Name
03/042022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
(Donation
` 0❑Removal Datelaemoved
x and/or an r Held
NHold Address
2 to:TransportationDate Point of
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
pReinterment
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
F— Remains are Shipped,If Other than Above
a Address
IX
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03d04/2022 Registrar of Vital Statistics TiffZee 0Conncr(' sctwn 504
(signature)
District Number 4520 Place mows of Ballston Spa
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WW Date of Disposition 3 q 111 Place of Disposition T'µU� r+�
(address)
W
CI
tr (section/ (lot number) (grew number)
Q
Name of Sexton or Person in Charge of Premises 'f`1,6. ' -c't"frt
Z (pte print)
WA ..../
Signature Title fi' r
DOH-1555(o7/18)p 1 of 2
•
015842
Public Health Law Sec. 4145(2b)
Receipt
,
Human remains of ' delivered on , 20
/
Pine View Cemetery Representing the funeral home named onbial permit
Official Funeral Directors Reg.or License#