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Burk, Richard Otto
tO it s(S. NEW YORK STATE DEPARTMENT OF HEALTH t" Burial - Transit Permit Bureau of Vital Records y Name First Middle Last Sex Richard Otto Burk Male Date of Death Age If Veteran of U.S.Armed Forces, 06/25/2023 78 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death El Natural Cause Accident ❑Homicide ESuicide Undetermined ri Pending W Circumstances Investigation W Medical Certifier Name Title 0 Melody Long PA Address 100 Park Street,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 310 Burial Date Cemetery,Crematory or Facility Name 06/27/2023 Pine View Crematory Entombment — Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held NHold Address 0 fl Date Point of (/)ETransportation Shipment $ by Common Carrier Destination —017isint rment 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 1— Remains are Shipped,If Other than Above 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/26/2023 Registrar of Vital Statistics Megan Wolin(ECectronicaQy Signet() (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: Z Date of Disposition 4.I Zl I 1,3 Place of Disposition ri•JL [ 2 (address) W N CC (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Prem. s f' '` l `l/ Z (p/e se print) W �` ( �? Signature Title DOH-1555(07/18)p 1 of 2 *s 7fl 7 Public Health Law Sec. 4145(2b) ` v Receipt Human Huthan remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#