Bain, Donald 1b
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'j' Donald P. Bain Male
Date of Death Age If Veteran of U.S. Armed Forces,
rr.•, January 4, 2016 89 War or Dates
{ Place of Death Hospital, Institution or
City, Town or Village Malta Street Address House Of The Good Sheperd
Manner of Death
X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
.At William Borgos MD
rti Address
161 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
;:;r_;:; City, Town or Village Malta
El Burial Date Cemetery or Crematory
January 6, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Glens Falls,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
N
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:; Permit Issued to Registration Number
: ; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
*.x: 53 Quaker Road, Queensbury,NY 12804
•:•, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above IAddress
'::: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l- en,1 016 Registrar of Vital Statistics RQ. ,c.t_i:
(si re)
District Number $L, o Place rn _
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition /-7-/(, Place of Disposition ?;-)g._ (Ji euJ le-Malec/
W (address)
N
Ct (section) (lot umber) (grave number)
0
p Name of Sexton or P rs in Charge of Premises J ti.i. vz rrta_ch&
Z (please print)
W
Signature Title G i'g-mc. o e"
(over)
DOH-1555(02/2004)