Burch, Louis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Louis Henry Burch Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 13 1999 54 War or Dates
Place of Death Hospital, Institution or
City, Town, or Village Granville Street AddressResidence
Manner of Death ❑ Natural Cause ❑ Accident ❑ Homicide Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Max Crossman M.D. Dr.
Address
Granville 12832
Death Certificate Filed District Number Register Number
City, Town or Village Granville 6^74, Q
Date Cemetery or Crematory
❑ Burial October 19, 1999 Pine View Cremator
Address
Cremation uaker Road Oueensbury, NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
❑
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01233
Address
123 Main St. , Argyle, NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the humar: zerins described above as indicated.
Date Issued /Q - j Registrar of Vital Statistics
(sig ature)
District Number S'-7G Q Place Granville,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (�� Place of Disposition Di�f/' fill%w C(`e,In a l G!'y
( ddress)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises M J'al 6 C-. Ap+&2,
(please print)
Signature Title e�rYs