Paddock, John • NEWWORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Nicholas
Date of Death Age If Veteran of U.S. Armed Forces,
September 1994 11 War or Dates no
Place of Death Hospital, Institution or
City, Town or Village City of Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Fred P. Scialabba M
Address 454 Glen Street, Glens Falls, New York 12801
Death Certificate Filed District Number --FRegister Number
City, Town or Village City of Glens Falls
Date Cemetery or Crematory
❑Burial
Address
Cremation. Queensbury,, New York
Date Place Removed
Z❑Removal and/or Held
and/or Hold Address
to
Point of
Q Transportation Shipment
0 Date
by Common Destination
Carrier
Disinterment Date Cemetery Address
>` Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan and Denny Funeral Service, Inc. 01583
Address 26 Quaker Road, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby
`granted to dispose of the human remas described above as indicated.
Date Issued �1 `� Registrar of Vital StatisticsLo
(signature)
c
District Number Place
I certify that the remains of the decedent identified above were disposed m accordance with this permit on:
i^- _
Uj g Date of Disposition - 1 ( ' Place-of Disposition e' /V _ j//pIt) r�R �N lb 13 ljL) /11�
(address)
jWU
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises
z please print ,
W Signature / Title Iti 4-IC6�� 5
DOH-1555 (10/89) p. 1 of 2 VS-61