Nicholson, Alexis I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
AT,RXTS DTANA NTCHOT,SON • FFMAT,F
Date of Death Age OYRS If Veteran of U.S. Armed Forces,
0 3/7 7/2 017 War or Dates
}- Place of Death Hospital, Institution or
Z City, Town or Village ALBANY, NY Street Address ALBANY MEDICAL CENTER
O Manner of Death 0 Natural Cause Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
V Circumstances Investigation
W Medical Certifier Name Title
0 ORY HOLTZMAN MEDICAL DOCTOR
Address
43 NEW SCOTLAND AVE. , ALBANY, NY
Death Certificate Filed District Number Register Number
City, Town or Village ALBANY 101
Burial Date Cemetery or Crematory
❑Entombment 03/30/2012 ST. ALPHONSUS CEMETERY
al Address
❑Cremation 52 LUZERNE RD. , QUEENSBURY, NY 12804
Date Place Removed
Z Removal and/or Held •
0❑and/or
Address
t'i)
Hold
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Eiii❑Reinterment Date Cemetery Address
ig:tE Permit Issued to Registration Number
Name of Funeral Home REGAN & DENNY FUNERAL SERVICE 01443
Address
53 QUAKER RD. , QUEENSBURY, NY 12804
'> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
tt
w
Permission is hereby granted to dispose of the human remains described above_ as indicated.
Date Issued c2J/2y/z /z Registrar of Vital Statistics 4 .2%'��
(signature)
District Number Place
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Iii Date of Disposition Place of Disposition � l
6 W ( da dress)
tki
CO
CC (. ion) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
i Signature Title C\ clj i
•
(over)
DOH-1555 (02/2004)