Bacon, Douglas F N,
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
DOUGLAS MICHAEL BACON MALE
Date of Death Age If Veteran of U.S.Armed Forces,
03/01/2017 71 War or Dates
I— Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
ILI
a Manner of Death Natural Undetermined ❑ Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide ElCircumstances Investigation
WMedical Certifier Name Title
CI LI ZHANG MD
Address
43 NEW SCOTLAND AVE., ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 493
Date Cemetery or Crematory
❑ Burial 03/03/2017 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
H Hold
7)
Date Point of
d Transportation Shipment
V) ❑ By Common 6 Carrier Destination
❑ Date Cemetery Address
Disinterment
IDDate Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. KILMER FH 01079
Address
82 BROADWAY FORT EDWARD NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
a. Permission is hereby granted to dispose of the human remains descri above mdica
Date 03/02/2017 g. t 1 /� 1 14a..4(...,
Issued
Registrar of Vital Statistics '� "
(sig a re)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
zDate of Disposition 311 111 Place of Disposition ?nr�.��,,r jr'►*6,�fiu.,
W (address)
2
W
co
Ce (section) is lot number) (grave number)
O
C
WName of Sexton or Person in Charge of Premises �. rr1�/' ��N�e It
/ j
(please print)
Signature ii 0 Title 113'EIZA
(over)
DOH-1555 (02/2004)