Bacas, William v il 3113
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
01William A. Bacas Male
Date of Death Age If Veteran of U.S. Armed Forces,
0 Ma 25 2014 82 War or Dates
Place of Death Hospital, Institution or
. City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death I XI Natural Cause n Accident El Homicide n Suicide Ini I Undetermined Iri I Pending
Circumstances Investigation
Medical Certifier Name Title
Rosl Socolof, MD
4 Address
42 Gurney Lane,Queensbury,NY 12804
Death Certificate Filed Queensbury,NY District Number Regi ter Number
is City, Town or Village 5657 (p
❑Burial Date Cemetery or Crematory
May 27, 2014 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ 7 Removal and/or Held
2 and/or Address
Hold
Cl)
0 Date Point of
O. Li Transportation Shipment
p by Common Destination
Carrier
ri Disinterment Date Cemetery Address
IT Reinterment Date Cemetery Address
;:w Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
f g
Address
r 407 Bay Road, Queensbury, NY 12804
go Name of Funeral Firm Making Disposition osition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains described above as indicated.
�,� Date Issued S c�
g �t gistrar of Vital Statistics
'' (signature)
1��r
District Number Place Queensbury,NY
r, 5657
4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 7
W Date of Disposition 5./2`>5/1ti Place of Disposition 'G ,W C.-renct0riv---^
W (address)
N
IY (section) � (lot numb (grave number)
pi Name of Sexton or Perso in Charge of Premises i 30,1(4
Z ( lease print)
W Signature Title CariliTert
(over)
DOH-1555(02/2004)