Nichols, James ter. 4 137
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Loomis Nichols Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/18/2018 90 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death J Natural Cause ❑Accident p Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 139
El Burial Date Cemetery or Crematory
03/21/2018 Pine View Crematory
El 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
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/19/2018 Registrar of Vital Statistics pp6ertA Curtis(EYectronicaltySigned)
(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 :3 J 22 hi Place of Disposition r„��
(address)
(section) J/pot numbs) (grave number)
Name of Sexton or Person in Charge of Premises 6/�hr J4,4
41-
(p ase print)
Signature Title /Of MRY1--
(over)
DOH-1555 (02/2004)