Nichols Jr., Winfield EZO
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Winfield Scott Nichols Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/05/2017 74 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 17❑Pending
Circumstances Investigation
Medical Certifier Name Title
Farhana Kamal MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 369
El Burial Date Cemetery or Crematory
07/10/2017 Pine View Crematory
DEntombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
ID Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker 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 07/10/2017 Registrar of Vital Statistics R,6ertACurtis cEkctronicalySigned
(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 703 i 1) Place of Disposition PIN V ti `ern(14o
(address)
(section) /' (lot number) (grave number)
Name of Sexton or Person in Charge of Premises l A rt.
Ste^1
r (ple se print)
Signature �^' /� Title r iZf 6111
(over)
DOH-1555 (02/2004)