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Bailey, Michael Richard L Ct NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Richard Bailey Male Date of Death Age If Veteran of U.S.Armed Forces, 11/18/2023 59 Years War or Dates H Place of Death Hospital,Institution or W City,Town or Village Queensbury Town Street Address 4 Baybrook Apt. D,Queensbury Town, New York 12804 p• Manner of Death Z Natural Cause Accident 0 Homicide Suicide Undetermined Pending V Circumstances Investigation In Medical Certifier Name Title Robert Reeves MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 172 Burial Date Cemetery,Crematory or Facility Name 11/22/2023 Pine View Crematory Entombment_ Address ©Cremation Queensbury Town,New York Donation 6❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 a. Date Point of L) Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom i— 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 11/22/2023 Registrar of Vital Statistics Caroline Ylifiegarcfe Barber(ECectronicaltySigned) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WR I I J/Date of Disposition 2�.. ZtZ 3 Place of Disposition rP► (.1 e V;e u,) Cr R_t a 2 (address) W CC N (section) (lot number) (grave number) fart v 4✓J 8 Name of Sexton or Person in Cha f Pre 'sesf A GOA Z (please print) W Signature $ /` Title Di PS4. DOH-1555(07/18)p 1 of 2 1..7c1 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#