Islas, Ted NEW YORK STATE DEPARTMENT OF HEALTH * 3 (
Vital Records Section li Burial - Transit Pit
Name First Middle Last Sex
TED BRIAN ISLAS MALE
Date of Death Age If Veteran of U.S.Armed Forces,
09/18/2012 46 War or Dates
1- Place of Death Hospital, Institution
W City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
a Manner of Death Natural Undetermined Pending
W ® Cause El Accident ❑ Homicide El Suicide ❑ Circumstances ❑ Investigation
W` Medical Certifier Name Title
a PREETHA KURIAN MD
Address
43 NEW SCOTLAND AVE., ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1786
Date Cemetery or Crematory
0 Burial 09/24/2012 PINE VIEW CREMATORIUM
0 Entombment Address
® Cremation QUEENSBURY, NY RtOLA
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
H Hold
N
Q Date Point of
a Transportation Shipment
V) ❑ By Common❑ Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home REGAN DENNY STAFFORD F.H. 01443
Address
53 QUAKER RD., QUEENSBURY NY 12804
i`' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
aAddress •
W"
- Permission is hereby ranted to dispose of the human remains de cribed above as' dicat d.
Date 09/20/2012 P Registrar of Vital Statistics ' v ti `�
Issued (signature)
District Number 101 Place City of Albany, NY pA0
I certify that the remains of the decedent identified above were disposed of in accordance with this/is permit on:
Z Date of Disposition 1/24 I n, Place of Disposition �n1 U.tu cd+.4or 1 bl..
W (address)
u.l
to
(Y (section) (lot number) (grave number)
O S0
Z Name of Sexton or Person in Charge of Premises kti)(4)..... tnn iI,
w (please print)
Signature Title 014-,�+/�-
(over)
DOH-1555(02/2004)