Loading...
Smith, Brian T o 1 H 1 t DEPARTMENT OF HEALTH f - '`! � Vital Records Section k Burial - Transit Permit Name First Middle Last Sex Brian Terry Smith Male Date of Death Age If Veteran of U.S.Armed Forces, May 27, 2014 32 War or Dates No t- Place of Death Hospital, Institution City,Town or Village City of Albany or Street Address Albany Medical Center © Manner of Death Natural Undetermined Pending W ❑ Cause ❑ Accident ❑ Homicide ❑ Suicide ® Circumstances ❑ Investigation WMedical Certifier Name Title 0 Melanie Ecung Deyss MD Address 43 New Scotland Ave., Albany, NY 12208 Death Certificate Filed District Number Register Number City,Town or Village City of Albany 101 1019 Date Cemetery or Crematory ❑ Burial May 30, 2014 Pine View Crematorium ❑ Entombment Address ►� Cremation Queensbury, NY Date 1 Place Removed Z Removal and/or Held 0 El and/or Address Hold Date Point of a Transportation Shipment V); ❑ By Common Destination O Carrier 0 Date Cemetery Address Disinterment Date Cemetery Address El Reinterment Permit Issued To Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address 68 Main Street, Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address Cd 0. Permission is hereby granted to dispose of the human remains described abov as indicated. Date May 29, 2014 e c - Cil Issued Registrar of Vital Statistics (signature) ,Nli District Number 101 Place City of Albany, NY N I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition rt j3ili Place of Disposition 'F ' I `*---- lu (address) 2 W' N re (section) (grave number) 0 `. Z" Name of Sexton or Person in Charge of Premi ses � (lot number) . d' a1 (please print) Signature 141 ✓ --- Title C'illeili trat (over) DOH-1555(02/2004)