Nichols, Malcolm Brain Sr. NEW YORK STATE DEPARTMENT OF HEALTH CP
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Malcolm Brian Nichols Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/23/2022 78 Years War or Dates Navy
E. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
ILI
0 Manner of Death ❑X Natural Cause IllAccident ❑Homicide Suicide nUndetermined ❑Pending
11.1
Circumstances Investigation
W Medical Certifier Name Title G
Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 60
X Burial Date Cemetery,Crematory or Facility Name
04/04/2022 Pine View Cemetery
Entombment
— Address
Cremation Queensbury,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
E- Hold Address
el
❑Transportation Date Point of
Esby Common Shipment
Carrier Destination
Disinterment D
Date Cemetery Address
Date Cemetery Address
❑Reinterment
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
E
Q' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/28/2022 Registrar of Vital Statistics Caroline JfitdegardeBar6er(ECectronicalTySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permitm on: /
Z Disposition �'4 7' Dispositional ( iy e t5 4Jj �,1 7C l / d� L��J—' —
W Date of lY Place of ��
2 (address)
au
N a CJ
Q /sertio (!t number)r/ (grave number)
GName of Sexton or Person in Charge of Premises /`>/)r 1 �� � 1
Z (please print)
W Signature Title -D1)7�.r //1_-mil
4.
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
012904
I Receipt
r
Human remains of r ; i l delivered on ,rk !.x' -4 , 20 2?-
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
NICHOLS
(14 ) Lot No. 4-C
Address 121 Sunnyside NO.Queensbury NY 12804 Section No.
Owner Malcolm & Karen Nichols Plot Seneca
Date 6/12/03
Approx. 67 Superficial ft.
Location Bounded on North by Vacant , South by Cassela , East by Path,
West by Vacant.
Corner Posts
Remarks
Deed No. (and changes) 3237
Payment Record Paid in Full 6/12/03 ($800.00)
Record of Interments L /1Cl✓17L
Pi
g C.,
4-
4
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s Q 5
L I/
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Form No. 01
NICHOLS
LF
NAME Malcolm Nichols Age: 78
Lot Owner: Malcolm & Karen Nichols
Lot# Seneca 4 C Grave# 1
Case: Concrete
Died: 3.23.22 . Interred: 4 .4.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine VIew