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Wells, Susan NEW'{O K STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit '' Name First c. Middle Last 1 Sex 1 _ :af 3i,-).&1 ry *I CAS S F 1 Date of Death j Age T If Veteran of U.S. Armed Forces, 0‘(2ri 1 2ii2 ,o►y �7 War or Dates N 0 . Place of Death Hospital, Institution or City, Town or Village ! Street Address Manner of Death i Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined Pending ! Circumstances Investigation Medical Certifier Name 0 Title 0 n j x-r1 __iArsP Pam} t lat _- '' Address __ -_ _I \2\ 'r Sca-e_ e,* n Lk-)___ v,rt_e, 10.1• I 3 a. ><:: Deat rtificate Filed r District Number ` Reg isterj"lumber i.!•11i City, Town r Village Ge j,\\ 5515u . 1 I Date I Cemetery or Crematory i Burial I _©_��_SOT o_9_ 01.. - csA- C1_> S �a\�S \�Qc r�l -1j Address El Cremationl U..Q9X1S�OU-ry, t Date lace Removed 2�Removal and/or Heid k and/or I Address N Hold 6 ! Date ?vent of Nn Transportation i Shipment E by Common Destination Carrier Disinterment Date • Cemetery Address Reinterment Date Cemetery Address <; Permit Issued to ,t 1 l� j Registration Number >? Name of Funeral Home(`'a�1na i d . /dike/ F1 nr(c2/ home 0! ) C Address 1-1111 ll LCra-Li #C 3-. , &L.u.e.nsbUtLi , Aiew Lk{/4- /0?1?0`1 .. y 1 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped, If Other than Above a Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued '-Vv 'Zc(y Registrar of Vital Statistics , _`� , I iii ature) District Number '1S Le) Place -i-Gt.v c- c— Grc.• sO\-e- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: fr WDate of Disposition 5/9/14 Place of Disposition West Glens Falls Cemetery 2 (address) iti Family Plot CA CC (section) (lot number) '(grave number) 0 Name of Sexton or Person in Charge of Premises Connie L. Goedert Z (please print) Superintendent Signature �CI' ,_ /� ?-ed&krTitle over) DOH-1555 (9/98)