Burchard, Faithe E. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Faithe E.Burchard 7Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/28/2019 92 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
p Manner of Death Natural Cause Accident Homicide 1:1Suicide Undetermined El Pending
W Circumstances Investigation
V
W Medical Certifier Name Title
Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town orVilla a Queensbury 5657
Burial Date Cemetery,Crematory or Facility Name
12/02/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
ElDonation
0 Date
Removal Place Removed
and/or and/or Held
~ Hold Address
N
O
11 Date Point of
fA ❑Transportation Shipment
p by Common
Carrier Destination
ElDisinterment Date Cemetery Address
10 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
�. Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/29/2019 Registrar of Vital Statistics Caro�ira �gar�fr dar6er(Electranrca�SrgnedJ
(signature/
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: `
I1—
Z Date of Disposition 171 Z III Place of Disposition Fia. "M-
W (address/
W
N (section) (lot number/ (grave number)
Name of Sexton or Person in Charge of P mises
(p ase print/
Z61
W Signature ZrTitle
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013118
Receipt
a
Human remains of .'',i� �, ``.,lt �i ,`�_ delivered on ! , 20_,
Pine View&metery /Representiing--&e-funeraf home named on burial permit
Official Funeral Directors Reg.or License#
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