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Nichols, Andrew W . • L 4,1Y? NEW YORK STATE DEPARTMENT OF HEALTH ` } Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Andrew W.Nichols Male Date of Death Age If Veteran of U.S.Armed Forces, 02/08/2022 87 Years War or Dates 55-57 i,.. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 111 Manner of Death ©Natural Cause El Accident El Homicide El Suicide 0 Undetermined 0 Pending W 0 Circumstances Investigation WQ Medical Certifier Name Title Gwendolyn Morris-Dickinson PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 95 Burial Date Cemetery,Crematory or Facility Name 02/11/2022 Pine View Crematory • Entombment Address lCremation Queensbury,New York Donation ZO ❑Removal Date Place Removed and/or and/or Held F- Hold Address N 0 ❑Transportation Date Point of o by Common Shipment Carrier Destination Disinterment Date Cemetery Address 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 i— Remains are Shipped,If Other than Above 2 Address Cr W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/11/2022 Registrar of Vital Statistics Megan Norin(ECectronicalfySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition s Zoe Place of Disposition D',J e L;e..J C r P.rt1,q- -4,ILI 2 (address) Ill CC N (section) (lot number) (grave number) gName of Sexton or Person in Ch e o Pre ises tar Y►'t O..J /1100 (please print) W Signature^c-- / Title v� J c DOH-1555(07/18)p 1 of 2 I , .� Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# -