Burkhouse, Loreli ,Y 11s�
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Loreli Burkhouse Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/20/2020 55 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Malta Town Street Address 52 Thimbleberry Road,Malta Town,New York 12020
`p Manner of Death ❑X Natural Cause Accident ❑Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Madeline Haas MD
Address
391 Myrtle Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Malta 4560 55
Burial Date Cemetery,Crematory or Facility Name
12/01/2020 Pine View Crematory
❑Entombment Address
EICremation Queensbury Town,New York
❑Donation
oz Removal Date Place Removed
and/or and/or Held
H Hold Address
0
0- Date Point of
Cl) u Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/01/2020 Registrar of Vital Statistics .7enniferMarie?fvlmes(E/ctrorricaf Signed)
(signature)
District Number 4560 Place Malta, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 17 70 Place of Disposition ,� IL
2 (address)
W
CC (section) (lot numbed (grave number)
CCJ
Name of Sexton or Person in Charge of P e ises l f`� .. d"1 A 011
Z (pl se print)
W /Signature Title �I/GlAkTn2
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 1, I 4.2 A 9
Receipt
Human remains of " ./ delivered on ; , 20
_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# / /-. 1