Jacobs, Nicholas x . a 4' qi
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nicholas G. Jacobs Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 29,2016 82 War or Dates
<i,,. Place of Death Hospital, InstitutioriBlie Stanton Nursing& Rehabilitation
City, Town or Village Queensbury Street Address Centre
• Manner of Death Undetermined Pending
�X�Natural Cause Accident Homicide Suicide
W. Circumstances Investigation
• Medical Certifier Name Title
0: Joanne Cooper
Address
152 Sherman Avenue,Glens Falls,NY 12801
Death Certificate Filed District Number gister Number
City, Town or Village Queensbury 5657 O Cp
❑Burial Date Cemetery or Crematory
11
Entombment August 1,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z 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
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
M Remains are Shipped, If Other than Above
g: Address
it
1 Permission is ereby granted to dispose of the human remains described a v as indicated.
Date Issued c6 l (c)01(D Registrar of Vital Statistic O, R.4---'.---
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed Ku
in accordance with this permit on:
III Date of Disposition $JZfl6 Place of Disposition ra Ez✓ —to
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W (address)
CO
IY (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises 601T1- ti
Z Ijf (please print)
W Signature Z4 �C`—_ Title �'ti Pk
i (over)
DOH-1555 (02/2004)