Bravo, Henry NEW YORK STATE DEPARTMENT OF HEALTH Burial _ Transit Permit,
Vital Records Section
Name First Middle '—` Last Sex
Henry Michael Bravo Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 19, 2015 War or Dates
I' Place of Death Hospital, Institution or
Ltl City, Town or Village Glens Falls Street Address Glens Falls Hospital
13 Manner of Death .i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined El❑ Pending
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(.) Circumstances Investigation
W Medical Certifier Name Title
0 Susan Bradford, M.D
Address
45 Hudson Avenue Glens Falls, NY 12801
th Certificate Filed r I District Numb ( n Reg' r Number
City, Town or Village G(.e()S Fca(s .kDO ' 7
Burial Date Cemetery or Crematory
June 22, 2015 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
G7 Date Point of
a ❑Transportation Shipment
t!? by Common Destination
O Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
M. Address
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• Permission is hereby granted to dispose of the human remains described above as ' dicated.
Date Issued 6r 2-'4 L5 Registrar of Vital Statistics CA.wnSZ
(signature)
District Number 5 60i Place t(3.A."5 Ve,1. \1 S tliki y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1- P n<v:- '.J crewta..4 ots'v�.
tij Date of Disposition 06/22/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
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Ce (section) (Ito /(lJot number) (grave number)
in Name of Sexton or erson it Charge of Premises tmo�kyiel�&
Z `- -----4" &I (please print)
W Signature Title Ct'2m f'ta)ny
(over)
DOH-1555 (02/2004)