Spellacy, Carol Jane ' LC:-F) Pr- r--)
NEW YORK STATE DEPARTMENT OF HEALTH w Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Carol Jane Spellacy Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/12/2022 87 Years War or Dates
i.., Place of Death Hospital,Institution or
WCity,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
p Manner of Death n Natural Cause Accident 0 Homicide Suicide Undetermined Pending
W L 1 Circumstances Investigation
W Medical Certifier Name Title
CI Brandii Baker NP
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 45
DBurial Date Cemetery,Crematory or Facility Name
08/15/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
ZO ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
V)0 Transportation
ES Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
M Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/15/2022 Registrar of Vital Statistics Shelley 9Kckernon(ECectronicallySigned)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition $Illo Ill. Place of Disposition .ri,,,� 6',—_
W
M (address)
W
Co (section) 1 eclot�number) (grave number)
0 Name of Sexton or Person in Charge of Premises
Z 7//�r��$.`• &11,4h
/please print)
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W Signature r--� Title (be)/i11e
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
1 Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
SPELLACY Lot No. 1c
Address Stitchman Towers Apt. 6 Jay St. Uens Palls NY 12801 Section No.
Owner Ralph & Carol Spellacy Plot Erie
Date January 11, 2008Approx. 133 Superficial ft.
Location Bounded on North by Vacant, on South by Road, on East by Vacant and West by Gnade
Corner Posts
Remarks 792-0622 / 745-8302
Deed No. (and changes) 3527
Payment Record Paid in full 1/11/2008 ($2200.00)
Record of Interments
n DF a VAcAnT
Ralph Spellacv 122/16 FB
.;
II - - VAC—Act
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Form No. 01
SPELLACY
NAME Carol Spellacy Age: 87
Lot Owner: Ralph & Carol Spellacy
Lot# Erie 1 C Grave# 2
Case:Urn
Died: 8.1 2.2 2 Interred:1 0.6.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine View