Bracken, John NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
VitaWRecords Section
4 Name First Middle Last Sex
John Bracken Male
Date of Death Age If Veteran of U.S.Armed Forces,
January 21, 2011 51 War or Dates No
I— Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address Albany Medical Center
p' Manner of Death Natural ❑ Undetermined ❑ Pending
LU ® Cause ❑ ❑Accident ❑ Homicide Suicide
Circumstances Investigation
8 Medical Certifier Name Title
CI Joseph Skowronek MD
Address
AMCH, 43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 164
Date Cemetery or Crematory
® Burial January 29, 2011 Pine View Cemetery
0 Entombment Address
0 Cremation
Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 0 and/or Address
H- Hold
Cl)5
d Transportation Date Point of
co' ❑ By Common Shipment
6 Carrier Destination
❑ Disinterment
Date Cemetery Address
ElDate Cemetery Address
Renterment
Permit Issued To Registration Number
Name of Funeral Home Regan & Denny Funeral Service 01464
Address
53 Quaker Road, Queensbury, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
g Address
W'
0- Permission is hereby granted to dispose of the human remains described abov as indicated.
Date January 24, 2011 Registrar of Vital Statistics t C` AV41
Issued (signatur f
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition 1/29/11 Place of Disposition Pine View Cemetery
w (address)
2
w Erie 44 C 1
co
ce (section) (lot number) (grave number)
O
G
Z Name of Sexton or Person in Charge of Premises Michael Genier
(please print)
{ Su erintendent
Signature Title P
(over)
DOH-1555 (02/2004)