Nickerson, Mark NEW YORK STATE DEPARTMENT OF HEALTH /t0 r
Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
06
1,40 Mark E. Nickerson Male
`
,< Date of Death Age If Veteran of U.S. Armed Forces,
4 06/29/2014 49 War or Dates
Place of Death Hospital, Institution or
City,Town or Village GLENS FALLS Street Address GLENS FALLS HOSPITAL
Manner of Death 0 Natural Cause 0 Accident ED Homicide ❑ Suicide 0 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name C // ,/
Title
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c2_ �s e k 7 ' 6,3(e„,„ ��/ /)—
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Death Certificate Fil-d District Number �� Register Dumber
z City, Town or Village i
0 Burial Date _ r Crem tory
06/30/2014 I� LjeP-r.#JU1 '" /0#7�'2?,.
❑Entombment Address
yet®Cremation 1 -e- j,ri-f 2' .mot/ - - /� 7
f'.f Date race Removed
Removal and/or Held
and/or Address
Hold
al
Date Point of
r Transportation Shipment
by Common Destination
Carrier
### Date Cemetery Address
0 Disinterment
mt
El Reinterment
Date Cemetery Address
s-44,,' Permit Issued to Registration Number
s n Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
svo Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
it Address
Permission is hereby granted to dispose of the human remains described above as+indicated.
4.1 Registrar WD,, ••
�� Date Issued 6/ 3 0 l 1� e g C. (signature)
)
t District Number 5 b 0 Place � �,� S �a
\\S / VV
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az• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition 1-('1'1 Place of Disposition '�fn4V,tui Crt fiL--
(address)
(section) (lot number) (grave number)
` - SI ly,j/
Name of Sexton or Person Charge of Premises (please print) 111Y���
Via: Signature /d'r4- At---s Title C'C
Tl
(over)
DOH-1555(02/2004)