Loading...
Nichols, Bruce William Jr. NEW YORK STATE DEPARTMENT OF H EALTH r - I U Bureau of Vital Records I F BurialTransit Permit Name First Middle Last Sex Bruce William Nichols Jr. Male Date of Death Age If Veteran of US.Armed Forces, 01/18/2024 50 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 543 Aviation Road,Queensbury Town, New York 12804 UJ 0 Manner of Death 0 Natural Cause Accident 0 Homicide ESuicide Undetermined E z 1 Pending W Circumstances Investigation W Medical Certifier Name Title O Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 18 Burial Date Cemetery,Crematory or Facility Name 01/22/2024 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 6❑Removal Date Place Removed - and/or and/or Held t—- Hold Address N 0 O. Date Point of V)ElTransportation Shipment p by Common Carrier Destination O Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address R UJ a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/22/2024 Registrar of Vital Statistics Caroline xlcfegarr e Barber(E(ectronically 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: I— Date of Disposition ; d,Ci- '%-'i Place of Disposition pi„ `/t{,� cry;r Y�c,�fy 2 (address) W Cl)LE (section) (lot number) (grave number) gName of Sexton or Person in Charge of Premises Jr-(JY SV,rr.S Z (please print) W Signature 242Title Gre,n4dor DOH-1555(o7/18)p i of 2 Public Health Law Sec. 4145(2b) `� g Receipt Human remains of _ delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License# —