Brockway, Mark Donald Jr. # (L8
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Male
Mark Donald Brockway Jr.
Date of Death Age If Veteran of U.S.Armed Forces,
08/20/2023 58 Years War or Dates 1983-1986
F— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
`p n Natural Cause {]Accident n Homicide {]Suicide n
Circumstances Investigation
U Title
W Medical Certifier Name
C3 Bo Li MD
Address
100 100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 391
Burial Date Cemetery,Crematory or Facility Name
08/22/2023 Pine View Crematory
nEntombmeni Address
{]Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
- and/or and/or Held
l—- Hold Address
N
0 Date Point of
(/){]Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
{]Disinterment
Date Cemetery Address
nReinterment
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
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/21/2023 Registrar of Vital Statistics Meganolia(5kectrarricall:y Sgne€9
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H /�
WDate of Disposition $I7.3iti'' Place of Disposition 1 ,V—(address) I'l
W
IE (section) jl(lot number) (grave number)
• Name of Sexton or Person in Charge of P mises (((//[`*' i
11—
Q (ple se print)
z
W Signature Title 1z ��Ct
DOH-1555(07/18)p 1 of 2
U k
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#