Nichols, Alice NEW YORK STATE DEPARTMENT OF HEALTH VO
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alice R. Nichols Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 30,2012 94 War or Dates
. Place of Death Hospital, Institution or
aCity, Town or Village Glens Falls Street Address Glens Falls Hospital
: Manner of Death Undetermined Pending
11.1
X Natural Cause Accident Homicide Suicide
Circumstances Investigation
lit Medical Certifier Name Title
a Dr. Nancy Carney MD
Address
HHHN- Warrensburg; Main St. , Warre sbur , NY 12885
Death Certificate Filed District Number Regis-ter Number
City, Town or Village 5601 tj
❑Burial Date Cemetery or Crematory
July 2, 2012 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
rn
O Date Point of
O.
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 •
i— Remains are Shipped, If Other than Above
S Address
AU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7/')-/C 2. Registrar of Vital Statistics L. C W
(signature)
District Number 5601 Place Glens Falls 770/ /o2g-jf/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition -i(3)i1 Place of Disposition ' in Ut..) 6 are,,,.,`
2 (address) _ _
W
ca
ix
0 (section) (lot numb (grave number)
Op Name of Sexton or Person in Charg of Premises �i.0' ,,rr sh►tfr-
w (please print)
Signature4- Title e4Mi}c -
(over)
DOH-1555 (02/2004)