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Burch, Eric Allen 1:1 (13) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Eric Allen Burch Male Date of Death Age If Veteran of U.S.Armed Forces, 05/14/2021 54 Years War or Dates 1984-1990 F Place of Death Hospital,Institution or WCity,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing 1111 Manner of Death © Natural Cause ❑Accident Homicide 1=1 Suicide El Undetermined [11Pending Circumstances Investigation W Medical Certifier Name Title Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 41 Burial Date Cemetery,Crematory or Facility Name 05/18/2021 Pine View Crematory Entombment Address Cremation Queensbury Town,New York 11 Donation • Removal Date Place Removed and/or and/or Held N Hold Address 0 C- Date Point of tl) Li Transportation Shipment by Common Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 'g Address Er W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/18/2021 Registrar of Vital Statistics Jenny Linda M MarteCfe(ECectronicaCCy Signed) (signature) District Number 5756 Place Granville, 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 5 I t 9 174 Place of Disposition err,—I L d 2 (address) W CC N (sea/on) (lot number) (grave number) • Name of Sexton or Person in Charge of Pr ses r`1,/hL S fi 0 (pie print) Z � �r 77y✓� lL Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) iJ 1.4 7 9 Receipt • Human remains of '� delivered on , 20, r; f . Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# f i