Nicholas Sr., Richard NEW YORK STATE DEPARTMENT OF HEALTH Pllit
Vital Records Section Burial - Transit
7 ', Name First Middle Last Sex
i'd.' Richard A. Nicholas,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
wi June 26, 2017 73 War or Dates
k. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 20 Hartford Ave, Apt. 20F
Manner of Deathu_ki Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Patricia Auer
:::, Address
Carey Rd,Queensbury,NY 12804
'-• Death Certificate Filed District Number Register Number
<r�r=; 9
r�:« City, Town or Village Glens Falls 5601 3 S 3
❑Burial Date Cemetery or Crematory
June.$ 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
IPermit Issued to Registration Number
{ :. Name of Funeral Home Regan Denny Stafford Funeral Home 01443
`„.. Address
53 Quaker Road, Queensbury, NY 12804
f 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.
{'{ /(r.{3 Date Issued E Z
? Registrar of Vital Statistics (1�}C,L,ur� ��•~.�• `
;sr g� to _,�, (signs re)
; ' District Number Place
}r 5601 Glens Falls. 1J ` ,
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition q`ZSin Place of Disposition fin.ki ‘r+r^ r`
W (address)
U)
Ce
O (section) Ili (lot number, (grave number)
Z Name of Sexton or Person in Charge of emises th.r' ' J
/� (p ase print)
W Signature !s" �y Title ��..EMA-R
(over)
DOH-1555(02/2004)