Burch, Blanche NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Blanche L. Burch Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/12/9 5 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Town of Argyle Street Address Pleasant Valley Infirmar
Manner of Death rx]Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Thomas Kandora, M.D.
Address
Upper Broadway Fort Edward, NY 12828
<[> Death Certificate Filed District Number Register Number
City, Town or Village Town of Arqyle 5750 16
Date Cemetery or Crematory
❑Burial 11/14/9 _ Pineview Crematorium
Address
Cremation Queensbury, NY
Date Place Removed
8 ❑Removal and/or Held
••• and/or Address
0
Hold
Q Date Point of
Q Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01221
Address
P.O. Box 277 Fort Ann, NY
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 human remains described above as indicated.
11/13/95
XXX
Date Issued Registrar of Vital Statistics
(signature)
District Number 5750 Place Town of Argyle, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,r , Ir W Date of Disposition /��Place of Disposition //Yi� -.FV G,/T,6-lw
(address)
ill
W
> (section) of number) ) (grave number)
G /y Name of Sexto or Person in Charge f Premises ,�J� � 2 M19 7 zM 4J
(please pant) Y
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61