Burch, Lawrence B ail # ilC
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lawrence B.Burch .. _ Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/07/2022 89 Years War or Dates 1955-1957
F, Place of Death Hospital,Institution or
W City,Town or Village Hartford Town Street Address 4437 State Route 149,Hartford Town, New York 12827
0 Manner of Death Ei Natural Cause Accident 0 Homicide 0Suicide ❑Undetermined n Pending
ILI
U Circumstances Investigation
W Medical Certifier Name Title
0 Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Hartford District Number Register Number
City,Town or Village 5759 11
RBurial Date Cemetery,Crematory or Facility Name
09i08/2022 Pine View Crematory
Entombment Address
OCremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
d. Date Point of
(I)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
-.. Remains are Shipped,If Other than Above
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/08/2022 Registrar of Vital Statistics Denise cPetteys(ECectronicalTySigned)
(signature)
District Number 5759 Place Town Of Hartford
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �
/-��—
W Date of Disposition 9,9I 1Z Place of Disposition �,,,�
(address)
W S
CC N (section) / (!ot number) 1"WIt (grave number)
GName of Sexton or Person in Charge of Premi "
/pl se print) /�
W Signature Title c �'�
DOH-1555(07/18)p 1 of 2
ppJ 1
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#