Bailey, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH # 327
Vital Records Section ., Burial - Transit Permit
Name First Middle Last Sex
Kenneth L. Bailey Male
Miii Date of Death Age If Veteran of U.S. Armed Forces,
06/22/2012 75 yearo War or Dates
t Place of Death Hospital, Institution or
ii City, Towrill� X Glens Fails Street Address Glens Falls Hospital
Manner of Death❑Natural Cause 0 Accident ❑Homicide 0 Suicide 0 Undetermined El Pending
IliCircumstances Investigation
O.
al Medical Certifier Name Title
0 Mark Hoffman M. D.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town56fillli XX Glens Falls 5601 303
M❑Burial Date Cemetery or Crematory
❑Entombment 06/25/2012 Pine View Crematorium
Address
iiD❑C,emation Queensbury, NY 12804 •
Date Place Removed
❑Removal and/or Held
and/or Address
F= Hold
CO
0 Date Point of
CL El Transportation Shipment
la by Common Destination
imi Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
MiiPermit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Mi Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LEI
P` Permission is hereby granted to dispose of the human remains described above as i 'cated.
Date Issued 06/25/2012 Registrar of Vital Statistics / A‘rj d , „4
(signature)
District Number 5601 Place Glens Falls
'' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Disposition
Date of Disposition (ciLl.(�2, Place of Dis p P,JUKv C�,.ytor4..--
(address)
Ill
CO
CC (section) 4 (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ri Se
(pl ase print)
Signature (if LTitle G ,. kVdt2i
(over)
DOH-1555 (02/2004)