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Burch, Charles Lawrence NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Charles Lawrence Burch Male Date of Death Age If Veteran of U.S.Armed Forces, 12/04/2021 67 Years War or Dates H Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital • Manner of Death ©Natural Cause ❑Accident tEl Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation WI Medical 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 575 ❑Burial Date Cemetery,Crematory or Facility Name 12/07/2021 Pine View Crematorium ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation z ❑Removal Date Place Removed and/or and/or Held Hold Address (/) 0 O. Date Point of U) ❑Transportation by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑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 1— Remains are Shipped,If Other than Above 2 Address CC C' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/06/2021 Registrar of Vital Statistics Obert Andrew Curtis(ECectronicaflySigned) (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 Z� Z� Place of Disposition 2 (address) W CC (section) lot number) � (grave number) • Name of Sexton or Person in Charge o ises P,' t. ✓>`1VU'1r d (please riot) Z W Signature Title L r i"Pit/t_ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on,bal.fermit Official Funeral Directors Reg.or License# l '