Burch, Rosemary Lynn Town of Queensbury
irk Certification of Cremation
� Pine View Cemetery and Crematory
This certifies that the remains of: Rosemary Lynn Burch
were cremated on May , 5 20 22 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death May , 3 20 22 Age 64
(Month) (Day)
Funeral Home Carleton F neral Home Registered No. 373
oo-//1/7
(Aut ized Signature)
Burch (!7!:1)
NAME Rosemary Burch Age: 64
Lot Owner: Felix & Agnes Burch
Lot# Oneida 194 Grave# 3
Case: Urn
Died: 5.3.2 2 Interred: 5.2 0.2 2
Funeral Home: Carleton Fh
Cemetery: Pine View
P.
-- .l P 13
NEWYORKSTATE DEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Rosemary Lynn Burch Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/03/2022 64 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause 'accident ElHomicide ❑Suicide ❑Undetermined ❑Pending
✓ Circumstances Investigation
WG Medical Certifier Name Title
Gamal Khalifa MD
Address
k'. 100 Park St,Glens Falls,New York 12801
• DeaAth Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 P46
Burial Date Cemetery,Crematory or Facility Name
05/04/2022 Pine View Crematorium
Entombment Address
Cremation Oueensbury Town,New York
DDonation
Eland/or
Date Place Removed
F and/or and/or Held
N Hold Address
0
O. Date Point of
(/) Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
DReinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson FaNs,New York 12839
Name of Funeral Firm Making Disposition or to Whom
I.— Remains are Shipped,If Other than Above
a Address
CC
if
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/04/2022 Registrar of Vital Statistics 5ffegan Nan fThetrvnicr,Sign
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
USDate of Disposition S�=Zp2L Place of Disposition Po ae Jy e,,) C' 4-
2 (address/
W
+CC (section) /lot limbed (grave number)
J r
Name of Sexton or Person in Charge of P ises �0/��itl/1 �
z (please print/
Ili --.4...4-----
Signature Title oe,„
DOH 1555(07/18)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#