Brouillette, Daniel A ,,, j:)- Z (I(
NEW YORK STATE MENT OF HEALTH �� Burial - Transit Permit
Bureau of Vital Recorordriss
Name First Middle Last Sex
Daniel A Brouillette Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/6/2024 71 War or Dates 6/30/1969-4/13/1971
H Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address DVAMC,113 Holland Ave.,Albany,NY 12208
ILJ
O Manner of Death ❑X Natural Cause IllAccident II1Homicide El Suicide Undetermined []Pending
ILI
Circumstances I 'Investigation
W Medical Certifier Name Title
G Lorilyn Cooley MD
Address
113 Holland Ave.Albany,NY
DeaHth Certificate Filed Albany District Number Register Number
City,Town or Village 198 013
Burial Date_ / Cemetery,Crematory or Facility Name
Entombment l7` 2� RA/e vint„/ CR-P- 74'Z ti
Address
gremation
Donation (lA )4'>i3(.417->7 At-1
Date Place Removed
O Removal and/or Held
N and/or
N Hold Address
0
O. Date Point of
U)El Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home (A -1-T-'"i F""'t p l/(7'11Ei /^VC OO-S"/
Address
60 / t-4,,v S-'; )4,.$)yc2,-.0 rAIl-7 N7 )'$3`%
Name of Funeral Firm Making Disposition or to Whom
i.. Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the huma re ain;3Aesc ' d-ab3ve aindicated.
Date Issued 3/6/24 Registrar of Vital Statistics s H. rnngton
(signature)
District Number 198 Place DVAMC,113 Holland Ave.,Albany,NY 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 3-0 2p2 f Place of Disposition —Roe kJ,e„t) Cre-piorlQ r_
WT / (address)
W
CC (section) J/(lot nu giber) (grave number)
Name of Sexton or Person in Charge of Premises,. <�1rs� �'o' .1� 'c ted
Z (please print)
W Signature Title 467-4"lei
DOH-1555(07/18)p 1 of 2
-
Public Health Law Sec. 4145(2b) . y
1 Receipt
1
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#