Burch, Rose _ii Lrii)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
k�... Name First Middle Last Sex
Rose Marie Burch Female
K Date of Death Age If Veteran of U.S. Armed Forces,
June 27,2015 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
ii Manner of Death X Natural Cause Accident Homicide Suicide I I Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
. : Phillip J.Gara Dr.
. Address
327 Broadway,Fort Edward,NY 12828
`. : Death Certificate Filed Distr}f.t�gym er Reg'ste,� Number
Mki
City, Town or Village . J, (p
❑Burial Date Cemetery or Crematory
June 29, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
E Hold
co
O Date Point of
N I I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
. Permit Issued to Registration Number
;: Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
iiiii Address
iiiii 53 Quaker Road, Queensbury, NY 12804
i:iii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the huma r ins descri e a ove indicated.
Date Issued 015 Registrar of Vital Statistics t'
e..........---. ( ignature) (
District Number 5-1 55 Place I�) ero E CN Vu
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z a
W Date of Disposition 4,__ _t- g5 Place of Disposition r j°}e tj?'LJ (r vICAor. �Nh
W (address)
N
O sectio ) , _ / lot number) (grave number)
Q Name of Sexton or Person in C =rge of Premises (t 4i 04 k I IV/ //.
Z / / (please print)
W . Title ('�MaToI�
Signature y laid--
Signature
(over)
DOH-1555(02/2004)