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Brockway, Bruce Allen Sr,
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Male Bruce Allen Brockway Sr. Date of Death Age If Veteran of U.S.Armed Forces, 01/23/2022 59 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital ILI O Manner of Death © Natural Cause ❑Accident 0 Homicide 1=1 Suicide El Undetermined 0 Pending Ill Circumstances Investigation W Medical Certifier Name Title O Heather Madigan DO Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 64 Burial Date Cemetery,Crematory or Facility Name 01/26/2022 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York El Donation Z Removal Date Place Removed 0 Eland/or and/or Held H Hold Address N 0 Date Point of U) Li Transportation Shipment p by Common -_ - Carrier Destination Date Cemetery Address 0 Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above M Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/26/2022 Registrar of Vital Statistics 'Dillon Moran(ElectronicautySigned) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 1/211 ZZ Place of Disposition F,ri,.....Ill ssl n� W (lot nu r) (grave number) U)CC (sea/on) gName of Sexton or Person in Charge of Premises r-c MIAl it Z �� (please print) LU Signature Title e +410A� DOH-1555(07/18)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#