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Nichols, Michael J
It %/ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael J.Nichols Male Date of Death Age If Veteran of U.S.Armed Forces, 05/31/2021 60 Years War or Dates Place of Death Hospital,Institution or ECity,Town or Village Mount Pleasant Town Street Address Westchester Medical Center aManner of Death ©Natural Cause El Accident 0 Homicide El Suicide 0 Undetermined 0 Pending IU Circumstances Investigation C \Medical Certifier Name Title © Juliet Meir Address 100 Woods Road,Mount Pleasant Town,New York 10595 Death Certificate Filed District Number Register Number City,Town or Village Valhalla 5957 424 ❑Burial Date Cemetery,Crematory or Facility Name 06/03/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held N Hold Address N a0; Date Point of ) Li Transportation Shipment O by Common Carrier Destination Date Cemetery Address ElDisinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom },, Remains are Shipped,If Other than Above Address W CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/02/2021 Registrar of Vital Statistics Susan Marmot(ECectronicallySigned) (signature) District Number 5957 Place Valhalla, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2'- _ Date of Disposition (p'u(I vlPlace of Disposition L (� / / W CU (section) number, (grave number) O Name of Sexton or Person in Charge of Pr ises A t `' 'lT please t/ UJ Z rOCK„NN Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014828 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#