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Nicols, Carol It NEW YORK STATE DEPARTMENT OF HEALTH �© Vital Records Section . • ? Burial - Transit Permit Name First Middle Last Sex Carol A. Nichols Female Date of Death Age If Veteran of U.S. Armed Forces, January 7, 2013 76 War or Dates Place of Death Hospital, Institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death , Natural Cause Accident ( 'Homicide n Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Christopher Hoy MD Address 102 Park Street Glens Falls NY 12801 Death Certificate Filed Glens Falls District Number Register Number City, Town or Village 5601 1 2- El Burial Date Cemetery or Crematory January 8, 2013 Pine View Crematorium ❑Entombment Address ❑x Cremation 21 Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address NH Hold 0 Date Point of N ❑Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom }� Remains are Shipped, If Other than Above aAddress w Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued V I ct t{ 13 Registrar of Vital Statistics W Ok.A4 ..Z- (signature District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition Place of Disposition (ia ConiQriv, 2 (address) W U) (section) (lot number) (grave number) QName of Sexton or Person in Charge o Premises SQMrIµ W (pl ase print) Signature Title Chi r r (over) DOH-1555(02/2004)