Nicholson, Theodore NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
THEODORE _ LIAM NICHOLSON MALE
Date of Death Age If Veteran of U.S. Armed Forces,
03/22/2012 0 YRS War or Dates
} Place of Death Hospital, Institution or
City, Town or Village ALBANY, NY Street Address ALBANY MEDICAL CENTER
la Manner of Death Undetermined Pending
izt QX Natural Cause �Accident �Homicide �Suicide [� [�
i Circumstances Investigation
0.
iii Medical Certifier Name Title
0. ORY HOLTZMAN MEDICAL DOCTOR
Address
43 NEW SCOTLAND AVE. , ALBANY, NY
11 Death Certificate Filed District Number Register Number
City, Town or Village ALBANY 101
®Burial Date Cemetery or Crematory
03/30/2012 ST. ALPHONSUS CEMETERY
D Entombment
Address
OCremation 52 LUZERNE RD. , QUEENSBURY, NEW YORK 12804
Date Place Removed
2 Removal and/or Held •
4❑and/or Address
`` Hold
0 Date Point of
ti.L. Transportation Shipment
L by Common Destination
::0 Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home REGAN & DENNY FUNERAL SERVICE 01443
Address
53 QUAKER RD. , QUEENSBURY, NY 12804
iillii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
11
Permission is hereby granted to dispose of the human remains described a ove as indicated.
s Date Issued 4:%31 Z y/�/z Registrar of Vital Statistics drid_4 `€
(signature)
ili District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
tit Date of Disposition Place of Disposition t I✓
00 (address)
ll
to
(section) (lot number) (grave number)
ti Name of Sexton or Person in Charge of Premises Pam+-''1 ` '
- (pease print).
eiiiiSignature10 c? Title 014,0119 e y
(over)
DOH-1555 (02/2004)