Burch, Harry NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section T .;
Name First Middle Last Sex
Harry Douglas Burch Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/12/2018 63 War or Dates n/a
ItPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 7F Swan Way
Manner of Death 0 Natural Cause ❑Accident ❑Homicide E Suicide ❑Undetermined p Pending
Circumstances Investigation
Medical Certifier Name Title
Thomas Portuese,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 11+1
❑Burial Date Cemetery or Crematory
❑Entombment Address
15, 2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
Cl) Date Point of
yaj ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
;" Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a s
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (t- I5-AO I ' Registrar of Vital Statistics `' - C-.._
(signature)
District Number 5ti,5I Place Q v e e n S hVr
I certify that the remains of the decedent identified above were di4osed of in,,accordance with this permit on:
ui Date of Disposition Pin I if Place of Disposition u..� t c11?rn
(address)
W
CO
0 (section) /l (lot numbers (grave number)
pName of Sexton or Person in Charge of Premises t hr,,�i,�., Jg ti*
Z ( ease print)
W Signature l-�' ,/�,� Title f(a lin Tel.
(over)
DOH-1555(02/2004)