Wells, Shirley NEW YORK STATE DEPARTMENT OF HEALTH
i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley M. Wells Female
Date of Death Age If Veteran of U.S.Armed Forces,
April 19,2006 77 War or Dates No
Place of Death Hospital, Institution or
l-' Town of Queensbury Westmount Health Facility
z City, Town or Village Street Address
� Manner of Death Q Natural Cause ❑ Accident El Homicide ❑ Suicide El Undetermined ❑ Pending
Circumstances Investigation
0, Medical Certifier Name Title
Ili1 Bernardo R.Villajuan Dr.
tt
Address
88 Broad St,Glens Falls,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 C-
❑ Burial Date Cemetery or Crematory
4/21/2006 Pine View Crematory
❑ Entombment Address
0 Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
p and/or Address
I= Hold
aN Date Point of
❑ Transportation Shipment
by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan&Potter 01734
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
Address
Gl:
per„ Permission is hereby granted to dispose of the human remai described above s�-' dicated.
Date Issued 47��yU,c Registrar of Vital Statistics , _% =- Ai `?-L--
(signature) a-"`-----,`,
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I- .
Z Date of Disposition 41, �y- , Place of Disposition 1~2 j /Y�: -VI f=1c-it5A-!j4 j i 1 (...)el
W
(address)
W
CCd
O (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises G 4 R.L t 0l• ivj.
CI
Z (please print)
W Signature G cf C f L���- Title C-f-K1...4t 4 7c /
DOH-1555(02/2004) (over)