Nickles, Larrey �(4
NEW YORK STATE DEPARTMENT OF HEALTH `'
Vital Records Section Burial - Transit Permit
1 Name First Middle Last Sex
j;r Larrey E.
Nickles Male
jDate of Death Age If Veteran of U.S. Armed Forces,
1 December 6, 2015 67 War or Dates
I Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 292 East Schroon River Road
gManner of Death I XI Natural Cause I I Accident I j Homicide Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Michael J. Greenblatt
Cf* Address
250 Delaware Ave,Delmar,NY 12054
;'fd Death Certificate Filed District Number Register Number
City, Town or Village Town Of Lake George 5651
III Burial Date Cemetery or Crematory
❑Entombment December 8, 2015 Pine View Crematory
Address
1 Cremation Quaker Road, Glens Falls,NY 12804
Date Place Removed
G,I I Removal and/or Held
and/or Address
H Hold
cn
0 Date Point of
N I 'Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;r•;:; Permit Issued to Registration Number
:: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
e.
�f 407 Bay Road, Queensbury, NY 12804
r f Name of Funeral Firm Making Disposition or to Whom
;1r:4 Remains are Shipped, If Other than Above
ii Address
ZN
�` Permission is hereby granted to dispose of the human re ins escribed above as indicated.
i
Date Issued /2 _ / c, Registrar of Vital Statistics �a , n, }�La 3
/ i(signatu ee)
a:
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1Z1Io J 1S Place of Disposition _�C ., U�„�/ (rt 4 p(c,,,.
W (address)
N
IX
0 (section) / pot number) (grave number)
Z se
Title Name of Sexton or Person in Charge of P mises r,/ ti/tV1}'
LIJ g (pi print
Signature /f fl /7
(over)
DOH-1555(02/2004)