Vaillancourt, Bryan Alexander . ,-r LF,
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NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bryan Alexander Vaillancourt Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/04/2023 25 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address St Margarets Center
ILI
p• Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Maria Devine MD
Address
27 Hackett Blvd,Albany, New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 0301
Burial Date Cemetery,Crematory or Facility Name
02/10/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or _ and/or Held
H Hold Address
N
0
a Date Point of
U)❑Transportation
Q by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
I.— Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/06/2023 Registrar of Vital Statistics Danie1Ce 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:
H
Z Date of Disposition 2-4-ZoZ3 Place of Disposition fR,JL Vie,,,) Ci` r-
2 (address)
W
U)
CC (section) lot number) (grave number)
O Name of Sexton or Person in Char of Pr e �FQ��i®/✓D j/1
Z (please print)
W Signature Title pei" Tar
DOH-1555(07/18)p l 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#