Nicolas, Manfred NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Manfred J. Nicolas Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/28/2013 87 War or Dates World War II
Place of Death Hospital, Institution or ,i,e, //-C 6 I/4.---e
wCity, Town or Village Chestertnim Street Address Deceased's Residence
fa Manner of DeathQ Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
WW Medical Certifier Name �� Title
Shannon Evens,
Address
6223 State Rte 9 Chestertown, NY 12817
Death Certificate Filed /! District Number I Register Numbe;�
City, Town or Village , - � b,j y //
❑Burial Date re atary
12/30/2013 1i.,.�6/l�Gs.� (�,q i
0 Entombment Address
®Cremation 6✓�,e e>-1-1S-jj 6/1 7 /f�y 1�-P,&`
Date Placre Removed
z ri Removal and/or Held
O and/or Address
F. Hold
0 Date Point of
a 0 Transportation Shipment
CD by Common Destination
El Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Ii- Remains are Shipped, If Other than Above
2 Address
ttt
a' Permission is hereb granted to dispose of the human re' -scrib- • = ;,%'e as • dicated`
Date Issued I . O /3Registrar of Vital Statistics d Acot_64( /
(sign re)
District Numbers fi59 Place J.%/-/� (7J^,���ia,),,th...._e,x_. 2 ��
I
i_
I certify that the remains of the decedent identified abov were disposed of in accordance with this permit on:
w Date of Disposition I/a 11-5 Place of Disposition r +� ,{pr,_.,
W (address)
fX (section) (lot number) (grave number)
zName of Sexton or Person i Char o Premises , .,tee,
(phase print) r
al Signature Title CPf, "'c'R)
(over)
DOH-1555(02/2004) ;,