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Pace, Vincent S :el NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Vincent S Pace Male Date of Death Age If Veteran of U.S.Armed Forces, 09/27/2023 73 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Lake George Town Street Address 21 Birch Avenue 2, Lake George Town,New York 12845 111 p Manner of Death ❑� Natural Cause illAccident ❑Homicide OSuicide Undetermined ❑Pending ill ✓ Circumstances Investigation W Medical Certifier Name Title O Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Lake George District Number Register Number City,Town or Village 5651 7 Burial Date Cemetery,Crematory or Facility Name 09/29/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held ~ Hold Address f) 0 a Date Point of Cl)❑Transportation p by Common Shipment Carrier Destination III Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 2 Address LC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/28/2023 Registrar of Vital Statistics (Patricia cN fMc?(inney-Schuster(ECectronicaltySigned) (signature) District Number 5651 Place Town Of Lake George I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 9-3Q—ZoZ3 Place of Disposition e ,a p VI e C,-e1.i q- jti� 2 (address) W N CC / (section) 9 (lot number) (grave number) g Name of Sexton or Person in Charge of Premises 1 Jn N1 �`�� �UdCi Z _ (please print) W Signature re� Title p�2rw r" DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 • Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#