Nick, Henry i . 1 Say
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
eg Henry J Nick Male
�
, Date of Death Age If veteran of U.S. Armed Forces,
07/17/2017 82 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death J Natural Cause 0 Accident E Homicide 0 Suicide ri Undetermined El Pending
', Circumstances Investigation
Medical Certifier Name Title
Kevin Dooley MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
oR City, Town or Village Saratoga Springs 4501 348
['Burial Date Cemetery or Crematory
07/19/2017 Pineview Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
,' Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
ii,�} Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
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.
41
Date Issued 07/18/2017 Registrar of Vital Statistics Jot 'Franck, EJctronicaaysrgnedt
(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:
Date of Disposition '7f ZO//7 Place of Disposition P, itZ i/ GPI t --& -a��/
(( (address)
(section) (lot number)um� (grave number)
F; Name of Sexton or P • har a of Premises 3 t^ (a � 17-1 - 4,Nn Z.
(please print)
Signature Title �/' 4�
(over)
DOH-1555 (02/2004)