Burdick, Catherine NEW YORK STATE DEPARTMENT OF HEALTH V t 4 Sr
Vital Records Section Burial - Transit r it
Name First Middle Last Sex
Catherine Ann Burdick Female
• Date of Death Age If Veteran of U.S. Armed Forces,
. 06/29/2017 85 WarorDates
$t
• Place of Death Hospital, Institution or
,� City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Ed Natural Cause ❑ Accident 0 Homicide C Suicide Undetermined El Pending
Circumstances Investigation
b Medical Certifier Name Title
John T. Quares i} a MD
Address
' 100 Park ST. Glens Falls, NY 12801
* Death Certificate Filed District Number Register u r
• City, Town or Village Glens Falls i_(06
Burial Date 0 7/0 3/2 01 7 Cemetery or Crematory
Pine View Crematory
�a ❑Entombment Address
W
0CremationQuaker Rd. Queensbury, NY 12804
Date Place Removed
��', Removal and/or Held
,; and/or Address
3j Hold
Date Point of
: :❑Transportation Shipment
zi by Common Destination
Carrier
Date Cemetery Address
.:, E Disinterment
EReinterment Date Cemetery Address
,, , Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan 01 821
Address
11 Algonkin St. Ticonderoga, NY 12883
r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
•` m
Permission is her by ranted to dispose of the human ains escribed Bove as ' dic d.
Date Issued ` of, ° ) i Registrar of Vital Statistics 177 l/0'-e-
';; (signature)
District Number Ol Place I-C,(__- �
0
zi I certify that the remains of the decedent identified above were disposed of in accoi >7 r nce with this permit on:
t '
+ii,, Date of Disposition "7� ill Place of Disposition -?ncti Z' ,",c o
address
4 (section) /'/(lot number) (grave number)
om, Name of Sexton or Person in Charge of Premises 7Ar.. �✓� S jjry'vir
::7 (please print)
1• Signature �''"'' Title (RE to VL
DOH-1555 (02/2004)