Brackett, Marie NEW YORK STATE DEPARTMENT OF HEALTH! N
Vital Records Section Burial - Transit Permit
4k1, Name First Middle Last Sex
• :x
Marie Cecile Brackett Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/10/2017 98 Years War or Dates
41
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address Westmount Health Facility
Manner of Death 5 Natural Cause El Accident Homicide El Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
r
_: Address
,4
.Eri 42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
"I City, Town or Village Queensbury 5657 138
['Burial Date Cemetery or Crematory
11/13/2017 Pine View Crematory
• ['Entombment Address
®Cremation Queensbury, New York
Date Place Removed
O Removal and/or Held
and/or
Address
Hold
Date Point of
Transportation Shipmer
by Common Destination
l' ' Carrier
g Q Disinterment
Date Cemetery Address
r
Reinterment Date Cemetery Address
Permit Issued to Registration Number
777, Name of Funeral Home Maynard D Baker Funeral Home 01130
gi Address
f tit
fit 11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Permission is hereby granted to dispose of the human remains described above as indicated.
g Date Issued 11/12/2017 Registrar of Vital Statistics caroline7rdar6er EkctronicatySigned-
. (signature)
t District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on:
Date of Disposition (if M'1 i 0 Place of Disposition ?1,4.-/- a ^ o;,./
(address)
(section) / (lot number) ( (grave number)
' ' Name of Sexton or Person in Charge of Premises I"r•3 J t""'a
1 (p/ se print)
k Signature Title litl t --
(over)
DOH-1555 (02/2004)