Burch, Carol NEW YORK STATE DEPARTMENT OF HEALTH ft 151
Vital Records Section `. . 16 Burial - Transit Permit
Name First Middle Last Sex
Carol Frances Burch Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 31, 2012 73 War or Dates
II Place of Death Hospital, Institution or
W City, Town or Village Hudson Falls Street Address 179 Main St., Apt 7
WManner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ElSuicide ❑ Undetermined ❑ Pending
t Circumstances Investigation
W Medical Certifier Name Title
C' Dr. Brian Kilpatrick,
Address
Mettowee Valley Family Health West Pawlet, VT
Death Certificate Filed District Number Register Number
City, Town or Village (S7a- (p g
❑Burial Date Cemetery or Crematory
June 4, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z ❑ Removal and/or Held
and/or Address
p: Hold
Date Point of
u.❑Transportation Shipment
N, by Common Destination
C1 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
Ce
d Permission is hereby granted to dispose of the human remains� described above as indicated.
Date Issued (o- /- ,i Registrar of Vita! Statistics o� eO s - �4.-/ —
(signature)
District Number j-7_z fo Place beQ��� /may :1-k x-- e.-6; i) _-
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition (4c1(L- Place of Disposition ..(7K0i.W Crrr►d*orJo -
'; (address)
tit`;
OTC
(section) (lot number), (grave number)
CI Name of Sexton or Person in Charge of Premises �i)g-cp i'' S'i'1l4
(please print)
Signature fZ g
� Title C tofni
(over)
DOH-1555 (02/2004)