Nicotra, Ronald 4 -- it 6111
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ronald Nicotra Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 20, 2013 65 War or Dates N/A
• Place of Death Hospital, Institution or
▪ City, Town or Village Village of Lake George Street Address 80 Montcalm Street
Manner of Death ❑ ❑ I I Undetermined I I Pending'O (�Natural Cause Accident Homicide Suicide
ha Circumstances Investigation
�> Medical Certifier Name Title
O Donald Merrihew
Address
Death Certificate Filed District Number �� Register Number ifCity, Town or Village Village of Lake George
0 Burial Date Cemetery or Crematory
❑Entombment July 23,2013 Pine View Crematory
Address
El Cremation Quaker Road, Queensbury,,NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
E Hold
U)
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
ri Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
� Remains are Shipped, If Other than Above
Address
M,
, Permission is hereby granted to dispose of the human rema' s described ab ve a i dicated.
Date Issued 77Z3 Registrar of Vital Statistics
��o 13
(signature)
District Number 5 G 20 Place Village of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � fi
Lt.! Date of Disposition 7-lW-t3 Place of Disposition '[l�M.VetiJ t sfotiv�
2 (address)
w
cn
0 (section) _ (lot number) (grave number)
QName of Sexton or Person in Charge of Premises t,,f} SP+ r'f
'Z lease print)
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Signature - Title CUT 014702
(over)
DOH-1555(02/2004)