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Burch, Mandy Renee tt s8 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mandy Renee Burch Female Date of Death Age If Veteran of U.S.Armed Forces, 11/06/2021 45 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause El Accident El Homicide El Suicide 1=1 Undetermined Pending Circumstances Investigation WMedical Certifier Name Title 0 Shahid Ahmed MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 494 ❑Burial Date Cemetery,Crematory or Facility Name 11/11/2021 Pine View Crematorium Entombment Address "'Cremation Queensbury Town,New York Donation 2 Removal Date Place Removed and/or and/or Held - Hold Address N 0 G. Date Point of U) L j Transportation Shipment by Common Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street, P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom H 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 11/08/2021 Registrar of Vital Statistics R96ert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, 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 �(112 ll� Place of Disposition AoLI- 4_ 2 (address) W CC (section) Jr (tot number) (grave number) 13 Name of Sexton or Person in Charge.of Premises r' 72 (�l ase printfSywitiA Signature Title DOH-1555(07/18)p 1 of 2 .11. 5 77 Public Health Law Sec. 4145(2b) Receipt Human remains of t delivered on , 20 Pine View Cemetery Representing the funeral home named onn bryrial permit Official Funeral Directors Reg.or License#