Burch, Darwin C .k
- # 03
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
iiPA Name First Middle Last Sex
era Darwin C Burch Male
`• Date of Death Age If Veteran of U.S. Armed Forces,
r October 25, 2014 66 War or Dates
•�r� Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I XI Natural Cause n Accident Homicide 'Suicide Undetermined Pending
Circumstances Investigation
i
Medical Certifier Name Title
Susanne Rayeski Dr.
ii:A Address
s 3767 Main Street,Warrensburg,NY 12885
. Death Certificate Filed District Numbe5601 Register Number
rlra$ City, Town or Village Glens Falls c / i 7 3
-•-a
❑Burial Date Cemetery or Crematory
October 27, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
I-- Hold
CO
O Date Point of
(n I I Transportation Shipment
a by Common Destination
Carrier
I Disinterment Date Cemetery Address
I Reinterment Date Cemetery Address
j;: Permit Issued to Registration Number
'? Name of Funeral Home Regan Denny Stafford Funeral Home 01443
?:r Address
rr? 53 Quaker Road,Queensbury,NY 12804
t:, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
-,
,
'r. Permission is hereby granted to dispose of the human remai s descrbed abov as indicate
Date Issued jQ/,,17��p/(1 Registrar of Vital Statistics r p� D?,,--‹
`. f (signature)
District Number 5601 Place Glens Falls 74Z /2 i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (o/tglt! Place of Disposition Fgt.,
(address)
W
Cl)
CL (section) ,(lot number) (grave number)
pName of Sexton or Person in Charge of Premises ` .4 - �.4iI
Z ` (please print)
W Signature l Title CizErird (
(over)
DOH-1555(02/2004)