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Burch, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Dorothy May Burch Female Date of Death Age If Veteran of U.S. Armed Forces, February 11, 2017 81 War or Dates F- Place OD ath Hospital, Institution or W' City,�T''own r Village Queensbury Street Address The Stanton Nursing & Rehab. Center Manner of Death j Natural Cause ❑ Accident 0 Homicide 0 Suicide ❑ Undetermined 0 Pending WdJl Circumstances Investigation W Medical Certifier Name Title ID Roslyn Socolof_MD, Address 100 Broad St Plaza Glens Falls, NY 12801 Deatr ificate Filed/; Di Number R ister Number Cit , ow r Village l LA€.P_ f ,sb v,s (.4 1 0 Burial Date Cemetery or Crematory February 14, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address -.. Hold Date Point of O.. ❑Transportation Shipment _ co by Common Destination 3', Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I--; Remains are Shipped, If Other than Above Address fX W' Ci' Permission is hereby gf anted to dispose of the human re5kbs described ab e, s indicated. Date Issued cD, 1 ) Li ( 1 '7 Registrar of Vital Statistics - _ L—� �`( - (signature) District Number_Sj '7 Place 1 G� t�--� Cyr` C_'' Q--- ).-._ —` I certify that the remains of the decedent identified above were disposed of in accordancewith his permit on: Ili /yy,,1 W Date of Disposition 0244./2017 Place of Disposition Quaker Road Queensbury,NY 12804 / -,,),�' z',,�'� e..� M (address) Wco ?' ce (section) \ (lot number) (grave number) ci Name of Sexton or Pefsgn;iin Charge of Premises 1 /f eh-p"l 6l,421�.c.,1IE'_ z (please print) W Signature _ �r'sh�`f? "'�� Title 4 'l G ' (over) DOH-1555 (02/2004)