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Burke, Kristopher M
N EW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kristopher M. Burke Male Date of Death Age If Veteran of U.S.Armed Forces, 02/12/2023 31 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Long Lake Town Street Address 167 Route 28 Route, Long Lake Town, New York 13436 pManner of Death ❑Natural Cause Accident I I Homicide Suicide ❑Undetermined ❑Pending U Circumstances Investigation W Medical Certifier Name Title 0 Carl Turner Coroner Address 1188 Main Street, Long Lake Hamlet,New York 12847 Death Certificate Filed Town Of Long Lake District Number Register Number City,Town or Village 2056 1 ElBurial Date Cemetery,Crematory or Facility Name 02/17/2023 Pine View Crematory �' Entombment Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed and/or and/or Held F- Hold Address CO 0 0. Date Point of t/) Transportation al Common Shipment Carrier Destination Date Cemetery Address Disinterment El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 5 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/16/2023 Registrar of Vital Statistics Dixie Lee Leblanc(Electronically Signed) (signature) District Number 2056 Place Town Of Long Lake • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Il— Z Date of Disposition Z-/e_ZAZ3 Place of Disposition ,C�p L2tzt) t i A UJ (address) W NCC (section) (lot tuber) (grave number) Name of Sexton or Person in Charge of Premise �A��IOd'�! , L GeJ Z (please print) W Signature (�� Title 4 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#