Bailey, Henniet F N 14 l',..:.—)F7.- ' . , _ -
EW Y•RKSTATE DEPARTMENT OF HEALTH Buriales
- Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Henriet F.Bailey Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/04/2022 73 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
LU
1pManner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
✓ Circumstances Investigation
W Medical Certifier Name Title
C3 Humaira Jami MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 277
laBurial Date Cemetery,Crematory or Facility Name
05/05/2022 Pine View Crematory
Entombment Address
▪Cremation Queensbury Town, New York
▪Donation
OZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
U)ETransportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
L' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/05/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— niti
Z Date of Disposition Jam`--G—Zo ZL Place of Disposition !!iJP v4.e C,` ss
W
2 (address)
W
CCCC (section) (lot umber) (grave number)
aName of Sexton or Person in Charge Premi s 1�141r/�D�'� on1�
Z e please print)
W /Signature �1+/' Title Qf�
DOH-1555(07/18)p 1 of 2
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#