Nicola, Benjamin NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Benjamin Francis Nicola Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/12/2013 71 years War or Dates
Place of Death Hospital, Institution or
lU City, Towiii /ilXX Glens Falls Street Address Glens Falls Hospital
ci Manner of Death❑ •f atural Cause 0 Accident Homicide Suicide Undetermined III Pending
J Circumstances Investigation
W Medical Certifier Name Title
Nawed A Sidrligiii M rl
Address
100 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TowzooyikICAXX Glens Falls 5601 535
ElBurial Date Cemetery or Crematory
Entombment 12/16/2013 Pine View Crematorium
Address
1=1C0-emation Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
9 and/or Address
H Hold
Cl)
Q Date Point of
5 El Transportation Shipment
el by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01821
>> Address
11 Algonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
2 Address
t
w
11
.. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/13/2013 Registrar of Vital Statistics L' ,ty L ,k)�/,.. `
(signatuYe)
District Number 5601 Place Glens Falls) N`I2
JF- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z 1 Date of Disposition I1s('-(3 Place of Disposition Zati.) ar,A ,rit., _
2 (address)
W
CO
Jr (section) (lot number) (grave number)
0.
ci Name of Sexton or Perso in Charge of remises dill.. 5,��t�Z ( se print)
Signature lc T' Title <-12,01131CIZ
(over)
DOH-1555 (02/2004)