Braniecki, Thomas Anthony # ItAtZ
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Anthony Braniecki Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/14/2022 72 Years War or Dates
p.,, Place of Death Hospital,Institution or
WCity,Town or Village Bolton Town Street Address 859 Trout Lake Road,Bolton Town,New York 12814
0 Manner of Death II Natural Cause IllAccident ❑Homicide Suicide Undetermined Pending
U Circumstances Investigation
G Medical Certifier Name Title
Bryan Smead MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Bolton District Number Register Number
City,Town or Village 5650 6
Burial Date Cemetery,Crematory or Facility Name
08/17/2022 Pine View Crematory
Entombment Address
['Cremation Queensbury Town,New York
['Donation
oz❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
a Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/17/2022 Registrar of Vital Statistics Jodi cPetteys(cCectronicallySigned)
(signature)
District Number 5650 Place Town Of Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 8(n't1 Place of Dispositiona
2 (address)
W
U)
CC (section) (lot-number) (grave number)
gName of Sexton or Person in Charge re ises n't
Z (pi se print)
fW Signature Title 6-1,014 Z
DOH-1555(07/18)p 1 of 2
*
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of , . delivered on , 20
— _
Pine View Cemetery Representing funeral home named on burial permit
Official Funeral Directors Reg. or License#