Nichols, Diane NEW YORK STATE DEPARTMENT OF HEALTH �O c
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Diane M. Nichols Female
Date of Death Age If Veteran of U.S. Armed Forces,
03 / 16 / 2016 73 War or Dates N/A
14 Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs, NY Street Address
Saratoga Hospital
3 Manner of Death®Natural Cause E Accident El Homicide Suicide ❑Undetermined �Pending
US Circumstances Investigation
igi Medical Certifier Name Title
Robert Hayes Jr. MD
Address
211 Church St, Saratoga Springs, NY 12866
ei Death Certificate Filed District N m pr Register Number
City, Town or Village Saratoga Springs, NY l ,1
>i DBurial Date Cemeter or Crematory
Mi 03 / 17 / 2016
LiEntombment Address
0.
ECremation
Date Place Removed
❑Removal and/or Held
and/or Address
E. Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
:' Disinterment Date Cemetery Address
iiiiiQ Renterment Date Cemetery Address
`i., Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
Ag Address
402 Maple Ave. , Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
•h Remains are Shipped, If Other than Above
Address
ft
Permission is h reb granted to dispose of the human remains d ' ed ov i ted.
Date Issued Registrar of Vital Statistics
(signature)
District Number L4 j t Place Saratoga Springs, NY , New York
#-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3�ig/j , Place of Disposition giv,ILCrtM+t�{vc�u�.1
(address)
iti
w
IE (section) (lot number) (grave number)
CIName of Sexton or Person in Charge of Premises t i ,,Si,Nat4d"-
Z (please print) •
W. Signature `"t Title �'WMi1lVIt
(over)
DOH-1555 (02/2004)