Nichos, Andrew James NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Andrew James Nichols Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/02/2020 21 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Keene Town Street Address Dix Mountain Trail,Keene Town,New York 12943
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined M Pending
W Circumstances Investigation
V
W Medical Certifier Name Title
0 Jay Heald Coroner
Address
7521 Court Street,Plattsburgh,New York 12932
Death Certificate Filed District Number Register Number
City,Town or Village Keene 1555 2
❑Burial Date Cemetery,Crematory or Facility Name
03/06/2020 Pine View Crematory
Entombment Address
)c Cremation Queensbury Town,New York
❑Donation
zRemoval Date Place Removed
and/or and/or Held
�- Hold Address
N
O
a Date Point of
N El Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reiwterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2020 Registrar of Vital Statistics E&nS Estes(E'lectronicady Syned)
(signature)
District Number 1555 Place Keene, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
Z Date of Disposition ,���oay Place of Disposition Q t- f
dress/
W
N (section) (lot nu ber) (grave number)
W
0 Name of Sexton or Person in C arge of Pre s �r'o
Z (please print)
W Signature f Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0133134
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#