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Burch Jr., Edward 444 I 4 . g) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit jj Name First Middle Last Sex Edward S.Burch Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 01/19/2018 72 Years War or Dates ia Place of Death Hospital, Institution or '€ City, Town or Village Ticonderoga Town Street Address Heritage Commons Residential Health Care Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined El❑Pending Circumstances Investigation it! Medical Certifier Name Title �` Kathleen Huestis MD Address 1019 Wicker St,Ticonderoga Town,New York 12883 Death Certificate Filed District Number Register Number City, Town or Village Ticonderoga 1564 5 El Burial Date Cemetery or Crematory 01/23/2018 Pine View Crematory El Entombment Address ®Cremation Queensbury, New York Date Place Removed Removal and/or Held and/or Address iiiHold Date Point of Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address _ L.jReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Wilcox&Regan 01821 Address 11 Algonkin St,Ticonderoga,New York 12883 Name of Funeral Firm Making Disposition or to Whom a Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/22/2018 Registrar of Vital Statistics Tonya M'Thompson(ECectronicallySigned) (signature) . District Number 1564 Place Ticonderoga, New York I certify that the remains of the decedent identified above were disposed of in accordance with/ this permit on: Date of Disposition /-25--/s Place of Disposition J�,�Q v l'c�J � i. (address) LI (section) (lot number) (grave number) Name of Sexton or on in C " rge of Premises I 1 �V _ C r�2 � � (please pit) Signature ' Title (over) DOH-1555(02/2004)