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Bailey, Donna J it 6 Li NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Per It Bureau of Vital Records Name First Middle Last Sex Donna J Bailey Female Date of Death Age If Veteran of U.S.Armed Forces, 01/14/2021 79 Years War or Dates F., Place of Death Hospital,Institution or WCity,Town or Village Schenectady Street Address Schenectady Center for Rehabilitation and Nursing o Manner of Death ©Natural Cause ❑Accident 1=1 Homicide ❑Suicide 1=1 Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title o Deborah Mutema NP Address 526 Altamont Ave,Schenectady,New York 12303 Death Certificate Filed District Number Register Number City,Town or Village Schenectady 4601 69 ❑Burial Date Cemetery,Crematory or Facility Name 01/19/2021 Pine View Crematory 0 Entombment Address ElCremation Queensbury Town,New York Donation Z Removal Date Place Removed O and/or and/or Held i Hold Address Q. Dater ~ ' Point of q) ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address 1=1Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/19/2021 Registrar of Vital Statistics Samanta R,Mykoo(Electronically Signed) (signature) District Number 4601 Place Schenectady, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:Z // G�1.� fJJ Date of Disposition I�21 I Zi Place of Disposition �,,,, (address) UJ CC (sewn/ a(lot number) (grave number) 0 L— P A t(t 0 Name of Sexton or Person in Charge o Premises o (plea*print) z 1YZ W ti� Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014430 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#