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Colios, Nicholas 1 -it* r— �11 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Nicholas Gregory Colios Male Date of Death i Age If Veteran of U.S.Armed Forces, 10/9/2014 ,84 War or Dates 1950-1953 Place of Death Hospital, Institution or City,Town or Village Glens Falls 1 Street Address Glens Falls Hospital Manner Of Death a Natural Cause 0 Accident ❑Homicide Suicide 0 Undetermined Pending Circumstances Investigation Medical Certifier Name Title CI Farhana Kamal Address 100 Park Street, Glens Falls,NY 12801 Death Certificate Filed District Number Register Number a City.Town or Village °Burial Date ' Cemetery or Crematory 10/14/2014 Pine View Crematory D Entombment Address GI Cremation 21 Quaker Road,Queensbury,NY 12804 Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of Transportation Shipment a bCommon Destination ier ©Disinterment 9 Date Cemetery Address 0 t Date Cemetery Address Reinterment i Permit Issued to ; Registration Number Name of Funeral Home M.B. Kilmer Funeral Home ( 01078 Address 136 Main Street, South Glens Falls,NY 12803 Name of Funeral Firm Making Disposition or to Whom h Remains are Shipped, If Other than Above Z Address CC ILI I' Permission is hereby granted to dispose of the human wins described above as indi Date Issued /v /o / Registrar of Vital Statistics District Number S�() / Place I certify that the remains of the decedent identified above were . posed of in accord . this permit on: Date of Disposition Mkt lI y Place of Disposition ..Rik,..)ik,..) (ir,.. (addr�s5J rso�cdonJ f�number) (grave number) Name of Sexton or Person in Charge of Premises n ,,�„AA, Z A � 9(��Sri f t Signature Title cpAt mirk (over) DOH-1555(02/2004)