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Nolan, Jeffrey 1 111 NEW YORK STATE DEPARTMENT OF HEALTH IL Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jeffrey Dean Nolan Male Date of Death Age If Veteran of U.S. Armed Forces, 11/13/2018 47 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Fl Manner of Death©Natural Cause Accident El Homicide EI Suicide ElUndetermined ri Pending Circumstances Investigation Medical Certifier Name Title .. Asim Chaudry MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 538 104 • ❑Burial Date Cemetery or Crematory 11/16/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury, New York Date Place Removed Removal and/or Held and/or Address Hold Date Point of Transportation Shipment by Common Destination Carrier re • Disinterment Date Cemetery Address � El Reinterment Date Cemetery Address Permit Issued to Registration Number hi Name of Funeral Home Wilcox&Regan 01821 ril Address 11 Algonkin St,Ticonderoga,New York 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above I Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/15/2018 Registrar of Vital Statistics qzgfertA Curtis g(ectronica1TySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition HIM its Place of Disposition 7 ,- l vr,.�.- (address) (section) Iflot number) (grave number) Name of Sexton or Person in Charge of Premises ` , rA. 1 (pi print) • Signature ] Title Ig tiNt (over) DOH-1555 (02/2004)