Nelson Jr, Andrew NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Andrew C. Nelson,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 7,2014 63 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
Mary C.Kilayko MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Registeri Vumber
City, Town or Village Glens Falls,NY 5601 //b
❑Burial Date Cemetery or Crematory
January 10,2014 Pine View Crematory
Entombment Address
0 Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
a 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
i— Remains are Shipped, If Other than Above
Address
a
Permission is hereby granted to dispose of the human remains de Dd ab ve n icated.
Date Issued 1-9-14 Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition vie%,y Place of Disposition RA U i
, ( nV a G f.—
W (address)
N
(section) (lot number) (grave number)
QName of Sexton or Person in harge of Premises SD^N br
Z ( 'ease print)
W
Signature � — Title t7 fi
(over)
DOH-1555(02/2004)