Brackett, Theresa NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Theresa Marie Brackett Female
Date of Death Age If Veteran of U.S. Armed Forces,
05 / 02 / 2017 76 War or Dates N/A
Place of Death Hospital, Institution or
ZCity, Town or Village Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death LX" Natural Cause 0 Accident ❑Homicide ❑Suicide � Undetermined �Pending
Circumstances Investigation
i l Medical Certifier Name Title
Q Rodney L. Ying MD
Address
59 Myrtle St # 300, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs �5(74 7 '7,
Burial Date Cemetery or Crematory
05 / 05 / 2017 1 Pine View Crematory
gi QEntombment Address
;:! ECremation Queensbury, NY
Date Place Removed
a Removal and/or Held
ia❑
E. and/or Address
Hold
ilj
O Date Point of
Transportation Shipment
6 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
<';`Q Renterment Date Cemetery Address
< Permit Issued to i Registration Number
ig Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave. , Saratoga Sp. , NY 12866
:iii:i Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
fir
iLI
( Permission is he eb granted to dispose of the human remains descrii d abo as indicated.
/ i� i am
Date Issued .`� y 7 Registrar of Vital Statistics ° l
s
(signature)
District Number L3o1 Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition IS]i? Place of Disposition 'h441.t.. Leirntjvr i,—,
(address)
ILI
VI
CC (section) r,/lot number) (grave number)
Q Name of Sexton or Person Charge of Premises
i g / k_r �. �A di
,' (p/eai a print) •
Signaturele' Title I. h`E.irr., '_.
(over)
DOH-1555 (02/2004)