Brackett, William NEW YORK STATE DEPARTMENT OF HEALTH #1 r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Brackett Male
Date of Death Age ` If Veteran of U.S. Armed Forces,
02 / 17 / 2017 85 War or Dates 1948-1952
-. Place of Death Hospital, Institution or
City, Town or Village Troy Street Address 328 6th Ave.
1iia Manner of Death r Natural Cause E Accident E Homicide _ Suicide ❑ Undetermined 0 Pending
Circumstances Investigation
u Medical Certifier Name Title
Q Xiao Su MD
Address
6 Medical Park Dr, Malta, NY 12020
Death Certificate Filed District Number Register Number ,,
City, Town or Village Troy 14 C Z
go Burial Date ; Cemetery or Crematory
02 / 21 / 2017 Pine View Crematory
DEntombment Address
Cremation Queensbury, NY
Date Place Removed
Z❑Removal ! and/or Held
2 and/or Address
f= Hold
0.
0 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care I 00364
Address
402 Maple Ave. , Saratoga Sp. , NY 12866
':> Name of Funeral Firm Making Disposition or to Whom
iiio Remains are Shipped, If Other than Above
2 Address
X
II E
Permission is hereby granted to dispose of the human remains described above indicated.
i Date Issued Cia}0.0 I l•l Registrar of Vital Statistics,...51,L _ 4. • ,,' ���. �
sign ate
)
District Number 1� Place
T/U c� /ca vj ,l� 'a,. 44/.,:,r^v.u—Txay New York
FI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition Zj L?I11 Place of Disposition iO-t.ar i; c1cc1��
2 (address)
fi
CC (section) / (lot number) (grave number)
Q
;p Name of Sexton or Person in Charge of Premises l)t;s' SamOt it
6 *fit (pl se print)
Signature + Title jr-rWet-
(over)
DOH-1555 (02/2004)