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Cassidy, Dereck NEW YORKSTATE DEPARTMENT OF HEALTH � Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dereck Cassidy Male Date of Death Age If Veteran of U.S.Armed Forces, 01/13/2024 55 Years War or Dates • Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 3 Balsam Drive 8,Queensbury Town, New York 12804 p Manner of Death Natural Cause Accident ❑Homicide 0Suicide FlUndetermined Fel Pending W Circumstances Investigation W Medical Certifier Name Title G Lynn Keil Coroner Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 9 Burial Date Cemetery,Crematory or Facility Name 01/18/2024 Pine View Crematory _Entombment Address ©Cremation Queensbury Town,New York Donation goRemoval Date Place Removed and/or and/or Held NHold Address 0 a Date Point of CO nTransportation Shipment b by Common Carrier Destination Disinterment Date Cemetery Address DReinterment 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 Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/18/2024 Registrar of Vital Statistics Caroline xCtfegarcfe Barber(ECectronica1TySigned) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition (q IN Place of Disposition .•) /4.4 2 (address) W Q (section) (lot numbed (grave number) 0 Name of Sexton or Person in Charge of Premises A,, lease print W Signature Title (Cf/1147.4 DOH-1555(07/18)p 1 of 2 IL 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#