Nelson, Kyle 1 4 311
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section .,,: " Burial - Transit Permit
Name First Middle Last Sex
Kyle Christian Nelson Male
z Date of Death Age If Veteran of U.S. Armed Forces,
4/22/2018 35 War or Dates n/a
P Place of Death Hospital, Institution or
11 City, Town or Village Saratoga Springs,NY Street Address Saratoga Hospital
Manner of Death �1Undetermined Pending I^I Natural Cause �Accident �Homicide E Suicide C n
Circumstances Investigation
Medical Certifier .., Name Title
& AsL-
C m Address
s
______l_n_6_ , . 1
TA ; Death Certificate Filed District Number Register NumbeL
���
City, Town or Village Saratoga Springs,NY ( 7
❑Burial Date Cemetery or Crematory
Entombment April 26,2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
Hold
N
0 Date Point of
O.
❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
i' Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
> Name of Funeral Firm Making Disposition or to Whom
s Remains are Shipped, If Other than Above
Address
Ty 3' Permission is h reby ranted to dispose of the human re airsI�d s. bed s indic d.
Pk
t . Date Issued '`� , I ' Registrar of Vital Statistics
41 : (signature)
1- , District Number ki 5D Place 5A4A---TVLIC:r (2. I(44-5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 5.'I /I$ Place of Disposition eµV... (4 4nc,...,
2 (address)
COILI
IZ
(section) /�I(tot number) (' (grave number)
pName of Sexton or Person in Charge of Premises ` kq J..4
Z // (p ase print)
W 4
Signature !� Title t PE v/1-
(over)
DOH-1555(02/2004)