Brueckner, Scott Christopher NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Scott Christopher Brueckner Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/27/2023 47 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Argyle Town Street Address 579 Coot Hill Road,Argyle Town,New York 12809
p Manner of Death ❑Natural Cause Accident Homicide [Suicide [Undetermined [Pending
W f 'Circumstances 'Investigation
0
W Medical Certifier Name Title
0 Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 64
[]Burial Date Cemetery,Crematory or Facility Name
12/30/2023 Pine View Crematory
IllEntombment Address
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
N[Transportation
Q by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
C Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
— 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 12/29/2023 Registrar of Vital Statistics ShefyMcfernon(ElectronicallyJgned)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
W Date of Disposition 114 j 2t Place of Disposition rluEi/FF-�.) toe�1AroP- y
2 (address)
W
CC (section) 4(!ot number)_ SA,t,t (grave number)
GName of Sexton or Person in Char Premises 6 +
W (please print/
foerw
Signature Title
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#