Nichinson, Barry NEW YORK STATE DEPARTMENT OF HEALTH t' '
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Barry C Nichinson Male
Date of Death Age I If Veteran of U.S. Armed Forces, ___
March 26, 2011 1 56 War or Dates
F- Place of Death ; Hospital, Institution or
Z City, Town or Village Glens Falls ; Street Address Glens Falls Hospital
aManner of Death [X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
us, Medical Certifier Name Title
O
Address
Death Certificate Filed T District Number Reg s tuber
City, Town or Village Glens Falls,NY 5601 I ` �-{
❑Burial Date ! Cemetery or Crematory
March 29 2011 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12801
Date Place Removed
ZO I I Removal ! and/or Held
and/or Address
F' Hold
O Date 7Point of
O.
Transportation Shipment
p by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
Permit Issued to i Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01464
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
'Fl Address
le
W — --- — -
• Permission is her by ranted to dispose of the huma -mains , -scribed a(�ove as indi,ated.
Date Issued Registrar of Vital Statistics / /1 " _ �� 4di—C
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above we - disposed of in accordance with this permit on:
Z '
W Date of Disposition 3-15 i2-1 r Place of Disposition ,n,c J tat,' C,^tfh-�t� 0,,,.._
2 (address)
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CC (section) (lot cumber) (grave number)
pName of Sexton or Person in Charg of Premises a f,Alio I Jt.1-i
Z (please print)
W 77?i _.. Title cap_Signature is'11}(c'L
(over)
DOH-1555(02/2004)