Randall, Brantley William (LF)
c
NEW YORK STATE DEPARTMENT OF HEALTH
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Brantley William Randall Male
Date of Death Age If Veteran of US.Armed Forces,
12/07/2022 7 Hrs. War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address Albany Medical Center Hospital
p Manner of Death 0 Natural Cause Accident Ej Homicide El Suicide FlUndetermined El Pending
W Circumstances Investigation
WMedical Certifier Name Title
G Marilyn Fisher MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 2863
Burial Date Cemetery,Crematory or Facility Name
12/12/2022 Pineview Crematory
Entombment Address
aCremation Queensbury Town,New York
EjDonation
0❑Removal Date Place Removed
and/or and/or Held
t-- Hold Address
N
0
d Date Point of
Cl)❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
a Address
Clt
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2022 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH ----7 h /7
Z Date of Disposition IZ I i3ltz Place of Disposition ,t
2 (address)
LU
CC (section) /a /lvtnumber) (grave number)
Name of Sexton or Person in Charge of Premises l't/1,, ktvL `..^.d`'h
(Ape print)
W Title lV ir)�1ThK
Signature
DOH-1555(o7/t8)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#