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Welch, Bruce Aaron r illi . CO BS- NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Bruce Aaron Welch Male Date of Death Age If Veteran of U.S.Armed Forces, 08/08/2021 64 Years War or Dates i_ Place of Death Hospital,Institution or WCity,Town or Village Lake George Village Street Address 81 Mohican Street 3,Lake George Village,New York 12845 p Manner of Death ©Natural Cause 0 Accident ❑Homicide 0 Suicide 0 Undetermined 0 Pending W C.) Circumstances Investigation W Medical Certifier Name Title 0 John Lukaszewicz MD Address 101 Ridge Street 2,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Lake George Village 5620 5 ['Burial Date Cemetery,Crematory or Facility Name 08/11/2021 Pine View Crematory 0 Entombment Address lCremation Queensbury Town,New York 0 Donation Z Removal Date Place Removed and/or and/or Held pN Hold Address 0 O. Date Point of N ❑Transportation Shipment Z5 by Common Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom i Remains are Shipped,If Other than Above 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/11/2021 Registrar of Vital Statistics Debra I Wckinney(ECectronically Signed) (signature) District Number 5620 Place Lake George Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- � WDate of Disposition SAZ, 1' Place of Disposition _ 2 (address) W CC (section) number) (grave number) Lit'L a( g Name of Sexton or Person in Charge of Premises r L. %1n„if t Z ---43' (p se print W Signature Title 4%0 K DOH-1555(o7/18)p 1 of 2 • Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#