Bailey, Nancy �. . . , /I0
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
.. Name First Middle Last Sex
rf Nancy Lee Bailey Female
f. Date of Death Age If Veteran of U.S. Armed Forces,
February 29, 2016 81 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Bolton Landing Street Address 14 South Beach Ave
Manner of Death Medical Certifier
X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Name Title
s Bryan Smead,MD
Address
:fee. 11 Cross Street,Bolton Landing,NY 12814
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: Death Certificate Filed District Number /� /'� Register Number
City, Town or Village �L(0�V 3
❑Burial Date Cemetery or Crematory
March 1, 2016 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO Removal and/or Held
and/or Address
H Hold
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O Date Point of
O. Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:r*; Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
;rr: 407 Bay Road, Queensbury, NY 12804
ir::; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
;;fir Permission is hereby granted to dispose of the human remains de cribed above a indicated.
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Date Issued 20ic. Registrar of Vital Statistics
-�-- (signature)
,, District Number 06,50 Place IUW� of. '31—"T if
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition 3j2 IJb Place of Disposition uVe 4,, l rtm4tgrun
W (address)
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W (section) f .(lot number (grave number)
pName of Sexton or Person in Charge of Premises Gl r,f ofL- 3e►i n-
Z (please print)
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Signature Title ft/CM-Wit
(over)
DOH-1555(02/2004)