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Nickerson, William t 93 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ' ' Name First Middle Last Sex William L. Nickerson Male Date of Death Age If Veteran of U.S. Armed Forces, April 7,2012 85 War or Dates -1946 ' Place of Death Hospital, Institution or Z' City, Town or Village Johnsburg Street Address 710 Harrington Road a' Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending Ili Circumstances Investigation tu Medical Certifier Name Title a Dr.John Rugge,MD Address HHHN,North Creek,NY 12853 Death Certificate Filed District Number Register Number City, Town or Village Johnsburg 5655 /a ❑Burial Date Cemetery or Crematory April 9,2012 Pine View Crematory ❑Entombment Address ©Cremation Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold N O 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 Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ▪ Address Ir tii a. Permission is hereby granted to dispose of the human r ins described above as i dicated. Date Issued q` q- (a , Registrar of Vital Statistics eo i- _ (signature) District Number 5655 Place Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z tu Date of Disposition , I0 Place of Disposition a u,a Col` o(NIA, W (address) co re (section) //��' (lot numberr- (grave number) Q Name of Sexton or Person in Charge of Premises (hril� 4r • fki� if Z dilk I (please print) tu Signature Title CQeYi1'i OQ- (over) DOH-1555 (02/2004)