Nolette, Terry I I . It #rg
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Terry R. Nolette Male
Date of Death Age If Veteran of U.S. Armed Forces, 1 9 7 0-1 9 7 2
6/1 4/2 01 7 67 War or Dates
- Place of Death Black Brook Hospital, Institution or 21 0 Nelson Rd
Z t I Town or VRI Street Address
ci Manner of Death x❑Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
ui Medical Certifier Name Title
; William Pelton MD
Address Plattsburgh, NY 12901
Death Certificate Filed District Number l c S Register Number
City,4 . r or Village 13G A OC $gook
❑Burial Date 6/2 2/2 01 7 C3ernatecy or Crematory
Pineview Crematory
❑Entombment Address Oueensbury, NY
DCremation
Date Place Removed
Z Removal and/or Held
2❑and/or Address
t Hold
tUf --
Date Point of
114, Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Thwaits- Zaumetzer Funeral Home Registration Number
Name of Funeral HomeTT
Address PoBox 127, Au Sable Forks, NY 12912
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
fr
la
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -) Z,,-- Z.0)1Registrar of Vital Statistics C 441 0.-1, --` vt---/ ,/
Town Of Black Bro
District Number 53 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Q
J Date of Disposition w*Iii I0 Place of Disposition f'ng a,,., aviNktori .,
(address)
ill
CO
CC (section) /�(Iotpumber)( (grave number)
ca Name of Sexton or Person in Charge of remises (f[►l<.T ✓\��I/t
(ple se print)
Signature �` d� Title (Y' iK
(over)
DOH-1555 (02/2004)