Loading...
Nichols, Barbara s 4t inc NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit V: Name First Middle Last Sex .: Barbara Jane Nichols Female rr Date of Death Age If Veteran of U.S. Armed Forces, December 8, 2015 86 War or Dates P ce of Death Hospital, Institution or Cit Town or Village Glens Falls, Street Address The Pines At Glens Falls anner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending LP, Circumstances J Investigation ' Medical Certifier 4 rF Name Title Melissa Decker Dr. ti Address f 9 Carey Road,Queensbury,NY 12804 •: h Certificate Filed District Number Register Number !•r• / g :_ r �Cit Town or Village (f��>°/js 1 �1� ��0/ �-- ❑Burial Date Cemetery or Crematory ❑Entombment December 10, 2015 Pine View Crematorium Address ©Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed Z ( I Removal and/or Held O and/or Address 1=. Hold N 0 Date Point of N I I Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address •j; Permit Issued to Registration Number :,: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address r•:•,'•�'', 407 Bay Road, Queensbury,NY 12804 V$ 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 huma remain describe above as ndica -d. f: Date Issued I� I U� (5 _ Registrar of Vital Statistics Or-e ej��'� 02,E ;r (signature) ' r District Number 6(�G�i Place I certify that the remains of the decedent identified above were disposed of inacccord/. .---,-;_<___zei an a with this permit on: Z Dispositionell L.- �rv"4"t'oc � Date of Disposition IZ�IK�15^ Place of ,v,.� W (address) CO (section) q�_ of num (grave number) 2 Name of Sexton or Person in Charge of Premises /'fps a' �i Iva- W /�1 (please pr7/t) Signature (e-'—� .L.r Title lizi^44601 (over) DOH-1555(02/2004)