Fisher, Nicholas `, na
71
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nicholas Fisher Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/21/2022 68 Years War or Dates Marines
Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
W Manner of Death X❑Natural Cause Accident El Homicide OSuicide Undetermined ❑Pending
Circumstances Investigation
aMedical Certifier Name Title
a Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 182
Burial Date Cemetery,Crematory or Facility Name
11/23/2022 Pine View Crematory
Entombment— Address
IICremation Queensbury Town,New York
❑Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
Cl) Transportation
a by Common Shipment
Carrier Destination
11
Date Cemetery Address
Disinterment
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/23/2022 Registrar of Vital Statistics Caroline 2fiCdegarde Barber(ECectronicalry Signed)
(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 permit on:
Wt- tvi______
Date of Disposition i 17d 1 7Z Place of Disposition
2 r_..,,„
s/
117
CC (section)
/section/ /iotnumberl (grave number)
_co,„4
8 Name of Sexton or Person in Charge of mises /n
2 (pi se print/
in Signature Title l /mE-I11h2
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
i
IPine View Cemetery Representing the funeral home named on burial pernilt
Official Funeral Directors Reg.or License#