Bailey, Jace r,„EWYORK STATE DEPARTMENT OF HEALTH ' # 3611
Vital Records Section Burial a Transit Permit
Name First Middle Last i Sex
0—GL[,,� D0.1,i e-\ (i I e
} Date of Death ; Age 1 If Veteran of U.S.Armed Forces
`-:_ a S" —/6 / d n I Co 61 j War or Dates
i= P T. of Death //� I Hospital, Institution Or//''� -. //S
i ty own or V ill-age/C� Ic 3 7(.S Street Address C.J/e!/>� / C`
0 !fanner of Death j Natural Cause Accident [l Homicide []Suicide Q Undetermined 0 Pending
nnn---»>lll Circumstances Investigation
fa
Medical Cps ler Name Title
L1c-v- le ` vn 1)1
Address
)a a par IL -ree f 6 /ep ��
. //6 /u y 1acPo 1
Certificate Filed S F �s 1 District Number �r I Register Number a
i City. Town or Village i .I 100 1 Ci
-_:., .IBurial ` Date i Cemetery or ematary
: ❑Entombment1 0 5 / 7 - / e /P,'n e Vi e(,J
Address
rematio &Uc 2� ���ee Y S v�r`-(
Date I Place Removed
egRRemovalI _D I and/or Held
a:ncjor I Address
01 I Date 1 Point of
E0 Transportation i Shipment
n -y Common 1 Destination
`.terrier I
I s nLerment Date Cemetery Address
�; I Date Cemetery Address
::: Fermi¢issued to i
Registration NumBaker Funeral Home oi130
Adr ess
11 Lafayette St, Queensbury, NY 12804
Na:.ri_of Funeral Firm Making Disposition or to Whom
5; Per airs are Shipped, If Other than Above
Adras _ . ..
m
4 Pern asiorb is hereby;granted to dispose of the human remains dssc.ibed above as indicated.
Date issued 5 1 / 712a6 Registrar of Vital Statistics rck.b Q t `. _ (signature)
District Number 560) _ Place 6 fv�i c . `�s
i I cer iy that the remains o3 the decedent identified above were disposed of in accordance with this permit on:
la 06:E 3r Disposition 5/f ti Place of Disposition FA,U..,, �r,Y.,c-hp,,.,
2I (address)
(section) /�lfar number) (grave number)
0) Name of Sexton or Person in Charge of Premises `k,� 51-V.'it
w; (Ri -4"Print)
Signature ._.. Title - MC 41 PA.-
(over)
DOH-1555 (02/2004)