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Quintois Jr., Andre Xavier �$ss NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Andre Xavier Quintois Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 12/24/2019 73 Years War or Dates 1966-1967 Place of Death Hospital,Institution or WCity,Town or Village Albany Street Address Albany Medical Center Hospital W Mannerof Death ©Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Benjamin Szewczyk MD Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2794 ❑Burial Date Cemetery,Crematory or Facility Name El12/26/2019 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation 2 Removal Date Place Removed and/or and/or Held N Hold Address O IL Date Point of to Ej Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address EjDate Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition orto Whom F Remains are Shipped,If Other than Above Address L'JC W 0' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/24/2019 Registrar of Vital Statistics Danieffe S Gillespie(ECectronicaCCy Signed) /signature/ District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H \ W Date of Disposition IZ IttVAlPlace of Disposition C Orvr— lu (address) til 1� (sedion) lllflot number/ (grave number) Q Name of Sexton or Person in Charge of Premises Z4 ea print/ W Signature //��tt� /plTitle DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013183 Receipt Human remains of delivered on 20 f _ Vjne View Cemetery Representing the funeral home named on burial permit `Official Funeral Directors Reg.or License#