Nichols, Michael r • _ \ 11 NEW YORK STATE DEPARTMENT OF HEALTH g�
Vital Records Section Burial - Transit Permit
` Name First Middle Last Sex
t . Michael Kevin Nichols Male
r Date of Death Age If Veteran of U.S. Armed Forces,
� €r
November 25, 2015 64 War or Dates
Place of Death Hospital, Institution or
U City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide ❑
Undetermined Pending
it Circumstances Investigation
Wj Medical Certifier Name Title
0 Farhana Kamal MD,
Address
Glens Falls Hospital Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
i City, Town or Village 5601
;IA❑Burial Date Cemetery or Crematory
December 1, 2015 Pine View Crematorium
ittt 0 Entombment Address
"-®Cremation Quaker Road Queensbury,NY 12804
iEkri Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
=,U): Date Point of
Transportation Shipment
t!) by Common Destination
0' Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
ttet- Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
'Ft Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
441 Remains are Shipped, If Other than Above
2. Address
a:
w
CLt
Permission is h reb granted to dispose of the human emains d scribed a 'ove aassJind�cated
Date Issue//351,� Registrar of Vital Statistics a _p ���!' Q2
(signature)
District Number 5601 Place 64$, ", , ) / ay
f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
w Date of Disposition 12/01/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
IJ,II
r' (section) 4/(lot
(lot number) (grave number)
aName of Sexton or Person in Char a of Premises i 4r4t+ . S 'r
z4 (please pri i nt)
Signature Title
(over)
DOH-1555 (02/2004)