Bakalis, Nicholas A 41 71i
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nicholas A.Bakalis Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/30/2021 84 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 36 Woodscape Drive, Moreau Town,New York 12828
W
'p Manner of Deathal, Natural Cause ElAccident ❑Homicide Suicide ElUndetermined ElPending
Circumstances Investigation
W Medical Certifier Name Title
Paul Filion MD
Address
3 lrongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 52
❑Burial Date Cemetery,Crematory or Facility Name
11/01/2021 Pine View Crematory
❑Entombment Address
gCremation Queensbury Town,New York
❑Donation
O• ElRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
Q. Date Point of
(/) 12 Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Service 01444
Address
94 Saratoga Ave,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/01/2021 Registrar of Vital Statistics LeeannLfccabe(fkctronican:ySigned)
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition i I(1 /i( Place of Disposition L L.
W (address)
W
CC (section) f�/4 (lot number) (grave number)
/�
G Name of Sexton or Person in Charge of Prem. s �� StrI'^�l�
Z (pi print)
W Signature Title fr' `
DOH-1555(o7/18)p id 2
L.'p i. f: {;. .f j/d. 7
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ',, ` delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#