Bailey, Chet N r ICP if s(o3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Chet N. Bailey Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/12/2022 42 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
0 Natural Cause Accident Homicide nSuicide I
Manner of Death Undetermined X Pending
nU Circumstances Investigation
W Medical Certifier Name Title
O Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 363
Burial Date Cemetery,Crematory or Facility Name
07/14/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
IIIDonation
O❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
CO
0
O. Date Point of
t/)0Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
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
F. Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/14/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�'.-)vr.�
W7 Date of Disposition lie i Z2 Place of Disposition �►'`��l'"' -
2 (address)
W
N
CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge o mises A Ni y
Ztolease print/ y.u��
tL Signature Title re
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#