Kirsch, David Dale 11(...._"-(-\)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Dale Kirsch Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/24/2023 79 Years War or Dates 1965-1970
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
WW Manner of Death
Natural Cause IllAccident Homicide Duicide Undetermined ❑Pending
V I—ICircumstances Investigation
ILI Medical Certifier Name Title
0 Andrea Hennessy NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 165
IBurial Date Cemetery,Crematory or Facility Name
03/29/2023 Pine View Cemetery
_Entombment Address
Cremation Queensbury Town,New York
Donation
ZO nRemoval Date Place Removed
and/or and/or Held
~ Hold Address
0
d Date Point of
U) Transportation
a" by Common Shipment
Carrier Destination
ElDisinterment 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
I— Remains are Shipped,If Other than Above
2 Address
CC
W
0' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/27/2023 Registrar of Vital Statistics Megan.No(in(ECectronicalty Signed)
(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: /„ jy
Z Date of Disposition J,p ,a3 Place of Disposition 2 f QL dQ lC.Q >?.L Atactlaxiiri f r
W 2 (address)
uJ SRIG 13E f
U) (section) (lot number) (grave number)
0 QI � .I�T
Name of Sexton or Person i0.Cbarge-6f5rT ises !1l11 C
Z , (please print) 1__ ww l/
W Asd..;„
Signature a .I. Title 51.L .r1 l +__j__ e.7�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 012972
Receipt
Human remains of �`, delivered on - - , 20
Pine N/iew Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
KIRSCH/DUPUIS LF
Owner
Helen Kirsch & Trisha Dupuis
Address Plot
36 Mechanic St. Ft. Edward, Nv 12828 Erie
Phone # Lot #
518-832-3956 73 E
Deed # Date
4375 3.27.23
Cost Foundation Y - N
&800.00
Location West-Vacant
South-Vacant
North-Wolff
East-Palmer
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY:
\*SIGNATURE: DATE: V9---7/4-A
SIGNATURE: DATE:
Record of Interments
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KIRSCH
NAME e:
David Dale Kirsch g 79
Lot Owner: Helen Kirsch & Trisha Dupuis
Lot# Erie 73E Grave# 1
Case: Concrete
Died: 3.2 4 .2 3 Interred: 3 .2 9.2 3
Funeral Home: Carleton
Cemetery: Pine View