Burch, Darwin NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
::* Name First Middle Last Sex
:rrf Darwin Burch Male
o.• Date of Death Age If Veteran of U.S. Armed Forces,
••-- Ma 3 2014 90 War or Dates WWII
• Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 17 Marion Ave
Manner of Death I Xi Natural Cause [ I Accident I J Homicide 1 Suicide Undetermined 1 Pending
r
Circumstances Investigation
Medical Certifier Name Title
ti: Eric Goe, MD
ff Address
65 Elm Street,Glens Falls,NY 12801
: Death Certificate Filed Glens Falls,NY District Number Regis- ./`r fiber
:rr •City, Town or Village 5601 -�}./��UU
•• ❑Burial Date Cemetery or Crematory
May 6, 2014 Pine View Crematorium
II Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ L ]Removal and/or Held
and/or Address
NF' Hold
0 Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::• Permit Issued to Registration Number
rf: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
: Address
✓ : 53 Quaker Road, Queensbury,NY 12804
:
rf Name of Funeral Firm Making Disposition or to Whom
r: Remains are Shipped, If Other than Above
Address
▪ Permission is hereby ranted to dispose of the human r ains des ribed abo e as indicated
Date Issued Registrar of Vital Statistics ii 6 L
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Place of Disposition .� .✓ [try...-•�d+.—
W Date of Disposition '5-�-l� p
ra (address)
W
N
Cr (section) / (lot nu er) (grave number)
pName of Sexton or Person in Charge of Premises 4 n . nGil
Z IL
print)
W Signature4 Title Catt"itit
(over)
DOH-1555(02/2004)