Woodard, Nickie - . '73j 4t -131
NEN YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nickie F. Woodard Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 3,2015 ""' 62 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
L; Medical Certifier Name Title
Siddiqui Dr.
Address
,Glens Falls,NY 12801
Death Certificate Filed District Number Regisz trier
City, Town or Village [�
❑Burial Date Cemetery or Crematory
Entombment October 6, 2015 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains des ribed ab ve a n icated.
Date Issued /0 /20/S— Registrar of Vital Statistics
(signature)
District Number s(,O/ Place /er,v, `5-/ ,4y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition /b f i/is Place of Disposition 5.1,0 41K
2 (address)
N
(section) (lot number (grave number)
Q Name of Sexton or Person in Char e of Premisesr.1Mw ti�c•.4'r
'LI Z (pl ase print)
Signature Title (IlkrZda
(over)
DOH-1555 (02/2004)