Burch, Andrew NEW YORK STATE DEPARTMENT OF HEALTH # ($1 g
Vital Records Section $ , Burial - Transit Permit
Name First Middle Last Sex
Andrew Burch Male
Date of Death Age ' If Veteran of U.S. Armed Forces,
October 12, 2013 23 War or Dates
Place of Death Hospital, Institution or
r City, Town or Village Glens Falls Street Address Glens Falls Hospital
7. Manner of Death=
Li Natural Cause X❑ Accident Eil Homicide Ei Suicide 0 Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Numbpr�ary Registerp5b r
City, Town or Village Glens Falls
❑Burial Date 10 r 1-1 1 z (3 Cemetery or Crematory
Pine View Crematory
4 ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
ft Hold
Date Point of
ril i
Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
t
Reinterment Date Cemetery Address
Permit Issued to Registration Number
''.'q Name of Funeral Home M. B. Kilmer Funeral Home 01079
j'`.=` Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
--.:4 Permission is here y granted to dispose of the human remains desc 'b d b as i ated.
Date Issued /0 !.S/2oi.2 Registrar of Vital Statistics 9
=
(signature)
District Number1/4„%ari
Place ‘IlpfjS AO./ ,O/ / 1/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
- Date of Disposition (okIII Place of Disposition Quaker Road Queensbury,NY 12804 a)
(address)
(section) (lot number) (grave number)
0• Name of Sexton or Person i Charge of emises C(n Sty
(please(print)
` ' Signature 9 TitletK
(over)
DOH-1555 (02/2004)