Bailey, David NEW YORK STATE DEPARTMENT OF HEALTH " ' ",« Ng
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
{ : David K. Bailey Male
Date of Death Age If Veteran of U.S. Armed Forces,
: r May 18, 2015 66 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 37 Third Street
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Pi Paul R.Filion,MD
Address
Irongate Center,Glens Falls,NY 12801
Ye Death Certificate Filed District Number Register Number
City, Town or Village 5 6 o 1 '2_S W
.. ❑Burial Date Cemetery or Crematory
May 21, 2015 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan -r Funeral Home 01596
r' Address
eee 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
': Remains are Shipped, If Other than Above
Address
gi
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued =') 2.0 ` 16 Registrar of Vital Statistic s LJCJ....vyy .Z .r
(signature)
. District Number 56(' t Place G � 1�, N /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I iiJ Place of Disposition mtl..J ( r+-�drr
2 (address)
W
CO
0 (section) lot Dumber) (grave number)
p Name of Sexton or Person in Charge of Premises it. J -
Z (pl ase print)
W a �,�
Signature (i�' Title a(`�C-i91f1"
(over)
DOH-1555(02/2004)