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Nichols, Elodie NEW YORK STATE DEPARTMENT OFF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Elodie Evel Nichols Female Date of Death Age If Veteran of U.S. Armed Forces, War or Dates »Place of Death Hospital, Institution or City, T Street Address Manner of Death Undetermined Pending stances Investigation Natural Causes❑Accident ❑ Homicide ❑ Suicide ❑ Circum ❑ Medical Certifier Name Title ..... Bernardo R. Villajuan MD Address -....Death Certificate Filed District Number Register Number City, Tc} Glens Falls 5601 ❑ Burial ate Cemetery or Crematory March 8, 1999 Pine View Crematorium © Cremation Address Th. of Queensbury, NY 12804 Date Place Removed ❑ Removal and/or held and/or hold Address Date Point of ❑ Transportation by Shipment Common,Carrier Destination Date Cemetery Address ❑ Disinterment Date Cemetery Address El Reinterment :::.:...:Permit issued to Registration Num Limber Name of Funeral Firm Carleton Funeral Hane Inc. � 00313 Address P.O. Box 67, 68 Main St. , Hudson Falls, N.Y. 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby gra ted to dispose of the human remains described abo as indi at Date Issued Registrar of Vital Statistics f (Signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were dispos d of in accordance with this permit on: �/ ( c Date of Dispositiom!54-w Place of Disposition (address) (Section) ,Q/,� (Lott Number) / (Grave Number) Name of Sexto or Person in Charge of Premises ���/��1 0 (Please Print) Signature �� � Title .5� DOH-1555 (10/89) p. 1 of 2 VS-61