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Burch, Patrick Charles AOF ,ti LioL NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Patrick Charles Burch Male Date of Death Age If Veteran of U.S.Armed Forces, 05/06/2023 42 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 1 Elizabeth Lane,Queensbury Town, New York 12804 ElWManner of Death Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation LLI 0 Medical Certifier Name Title Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 72 Burial Date Cemetery,Crematory or Facility Name 05/10/2023 Pine View Crematory Entombment Address ©Cremation Queensbury, New York Donation 0❑Removal Date Place Removed a and/or and/or Held Hold Address O a Date Point of (/) Transportation p by Common Shipment Carrier Destination oDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom — Remains are Shipped,If Other than Above g Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/10/2023 Registrar of Vital Statistics Caroline x&cfegarde Barber(ECectronicalTySigned) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: II— Z Date of Disposition Sjgi j z3 Place of Disposition •� \� (address) W CC (section) 1(1ot number) (grave number) Name of Sexton or Person in Charge of Premises A11, It (p se print) W Signature Title ��✓^AZ'� 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#