Kirchhoff, George D L.....c,F). _
1r bolo
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George D.Kirchhoff Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/09/2022 76 Years War or Dates
i,., Place of Death Hospital,Institution or
Z City,Town or Village Greenfield Town Street Address 7 Turkey Ridge,Greenfield Town,New York 12859
p Manner of Death El Natural Cause Accident Homicide []Suicide Undetermined ❑Pending
W
U Circumstances Investigation
Ili Medical Certifier Name Title
CI John Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Greenfield District Number Register Number
City,Town or Village 4557 20
ElBurial Date Cemetery,Crematory or Facility Name
06/11/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
f- Hold Address
N
0
a Date Point of
N fTransportation Shipment
5 by Common
Carrier Destination
Date Cemetery Address
Disinterment
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
t . Remains are Shipped,If Other than Above
2 Address
Q
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/10/2022 Registrar of Vital Statistics Karen S.Dowen(Electronically Signed)
(signature)
District Number 4557 Place Town Of Greenfield
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition G-ZZ-ZOZL Place ofDisposition AV (i`e,.c.9 ef'piv►4a: ri
W (address)
W
N (section/_Th (J�number) (grave number)
g°C rAy,„r„.,!5 /11007
Name of Sexton or Person in Charge f Premise (please print)
Z
W Signature Title DreTI
DOH-1555(07/18)p t of 2
*fib":
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#