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Burch, Nicole NEW YORK STATE DEPARTMENT OF HEALTH $ 2n11 Vital Records Section Burial - Transit Pe mit Name First Middle Last Sex Nicole Michelle Burch Female Date of Death Age If Veteran of U.S. Armed Forces, September 20, 2017 38 War or Dates I— Place of Death Hospital, Institution or W City, Town or Village Hudson Falls Street Address 70 John Street CI Manner of Death Natural Cause n Accident I I Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title CI AgeelA. Gillani, M.D. Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Hudson Falls }-j 7V-, ❑ Burial Date Cemetery or Crematory September 21, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held 0 and/or Address H Hold N Date Point of I Transportation Shipment CO by Common Destination p Carrier Date Cemetery Address El Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address W d Permission is hereby granted to dispose of the human rema. s escribed above as indicated. Date Issued ! 1) ` 0/7 Registrar of Vital Statistics (signature) District Number 5 ,C' Place \J4-\ gjA)„)._al.c....:*3 uU I certify that the remains of the decedent identified above re disposed of in accordance with this permit on: W Date of Disposition 09/21/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W (section) f lot number) (grave number) c, Name of Sexton or Person in Charge of Pr ises l nrf S SINI(t z ( (pl se print) W 9 Si nature �'�`�'� Title MEMO-- (over) DOH-1555 (02/2004)