Bailiff, Douglas I- 511 g
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firuouglas x
Middle esley Bailiff Se viale
Date of Death Age If Veteran of U.S. Armed Forces,
09/16/2013 38 years War or Dates
f4 Place of Death Hospital, Institution or
W City, i rX)gJ X Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
l Circumstances Investigation
tu Medical Certifier Name Title
II Richard Kim M D
Ac cir. urch Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, T 44r)V X Saratoga Springs 4501 382
❑Burial Date Cemetery or Crematory
09/17/2013 Pine View Crematory
0 Entombment Address
Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
42❑and/or
Address
CA
Hold
O Date Point of
N ❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
•
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Care, Inc. D0364
Address
402 Maple Avenue, Saratoga Springs, N Y 12866
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
a Address
IX
in
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/17/2013 Registrar of Vital Statistics
(signature)
Fiii District Number 4501 Place Saratoga Springs
11-
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 �
ILI Date of Disposition tit r1113 Place of Disposition -C,rtUtw Cr..401,.-..
(address)
W
CC (section) (lot number) S (grave number)
CI Name of Sexton or Perso in Charge of Premises df i �nN�
(ple se print)
• Signature 7I ..._ --s.-- Title Cc(mugtea
(over)
DOH-1555 (02/2004)