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Bacon, Ronald L.
ti'ry NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Ronald L Bacon Male Date of Death Age If Veteran of U.S.Armed Forces, 05/19/2021 68 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 326 Luzerne Road,Queensbury Town, New York 12804 pManner of Death © Natural Cause El Accident Ei Homicide ❑Suicide 0 Undetermined 0 Pending W V Circumstances Investigation In Medical Certifier Name Title 0 Aqeel Gillani MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 109 0 Burial Date Cemetery,Crematory or Facility Name 05/22/2021 Pine View Crematory 0 Entombment Address lCremation Queensbury Town,New York ElDonation Z ❑Removal Date Place Removed and/or and/or Held Hold Address CO Date Point of to Transportation Shipment S by Common Carrier Destination El Disinterment Date Cemetery Address Date Cemetery Address ElReinterment 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 }- Remains are Shipped,If Other than Above 511 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05121/2021 Registrar of Vital Statistics CarolineJ(iCdegardt Barber(E(ectronicaltySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition �?a_a?0a 1 Place of Disposition Pt uQ y':�..c.� �t-�!�'I�t �`� a (address/ W 1E (section) j(lot num ) (grave number) Name of Sexton or Person in Cha e of Premises rl ��'ele")d �. W60c (please print) z - s, / W Signature C y Title OeeT DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014808 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#