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Nichols, Donald I t # 3s1 NEW YORK STATE DEPARTMENT OF HEALTH N Vital Records Section Burial - Transit Permit Name First Middle Last Sex Donald Scott Nichols Male Date of Death Age If Veteran of U.S.Armed Forces, 04/30/2018 73 Years _War or Dates 1963-1966 Place of Death Hospital, Institution or ' City, Town or Village SIliaratoga Springs Street Address Saratoga Hospital 0 Manner of Death©Natural Cause 0 Accident 0 Homicide ❑Suicide ❑Undetermined ri 1--I Pending CircumstancesInvestigation pirE Medical Certifier Name Title a Joseph Hayes MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City, Town or Village Saratoga Springs 4501 259 DBurial Date Cemetery or Crematory 05/02/2018 Pine View Crematory DEntombment Address El Cremation Queensbury Town, New York Date Place Removed Z Removal and/or Held 0 and/or Address LI Hold 0 Date Point of Li C Transportation Shipment 0 by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 , Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped, If Other than Above ;mot Address re W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/02/2018 Registrar of Vital Statistics John rn Eranck(ECectronicarfy Signed) (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: 1111 Date of Disposition Slit lIs Place of Disposition ,ftt P t (address) 69 re (section) / lot number) (grave number) pName of Sexton or Person in Charge of Premises �Lr. z (pl se print) tL Signature a Title � R . (over) DOH-1555 (02/2004)