Nicolson, Ralphit sI
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last
Sex
Ralph Harry Nicolson
Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/06/2019
96 Years
War or Dates 1943-1946
II.-
Place of Death Hospital, Institution or
WCity,
Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death a Natural Cause Accident ❑ Homicide Suicide El Undetermined Pending
'p
U
Circumstances Investigation
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Medical Certifier Name Title
Yoram Amsalem MD
Address
211 Church St, Saratoga Springs, New York 12866
Death Certificate Filed
District Number
Register Number
City, Town or Village Saratoga Springs
4501
528
❑ Burial
Date Cemetery, Crematory or Facility Name
Entombment
10/08/2019 Pine View Crematory
Address
)C Cremation
Queensbury Town, New York
❑ Donation
z
Removal
Date
Place Removed
and/or
and/or Held
H
Hold
Address
N
O
0-
Date
Point of
N
Q
Transportation
by Common
Shipment
Carrier
Destination
Disinterment
Date
Cemetery Address
Reinterment
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
ll.-
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 10/07/2019 Registrar of Vital StatisticsSohnPaul!Fraack(E&tronica.yStgned%
(signature/
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate
of Disposition _ Place of Disposition v ! d(+�r�
(address)
W
N
�
(section/ Rot number/ (grave number)
_ S
GName
Z
of Sexton or Person in Charge of Premises (p
(p a print)
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Signature [_A Title
4
DO H-1555 (07/18) p t of 2
Public Health Law Sec. 4145(2b) 012584
Receipt
Human remains of delivered on
, 20 �
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License # I r ` - -,