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Wells, Frances -W . -7Ce I NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Frances Wells Female Date of Death Age If Veteran of U.S.Armed Forces, 11/16/2019 90 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Pending C.) Circumstances Investigation 0 Medical Certifier Name Title Eileen Spinelli NP Address 319 Broadway, Fort Edward Town, New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 92 Burial Date Cemetery,Crematory or Facility Name 11/18/2019 Pine View Crematory Entombment Address MV IS I Cremation Queensbury Town, New York Donation 0 Removal Date Place Removed and/or and/or Held i-N Hold Address O IL Date 7 Point of to ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/18/2019 Registrar of Vital Statistics AirrwMa'aW(Elafra4cafly9gW (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ � a-V �� Z4,11 Z Date of Disposition / _/� Place of Disposition Yl , W 2 /addre s/ W N cc (section/ (lot number) (grave number) CName of Sexton or Pers in ar Premises w l`�`'✓f Z (please print) W Signature Title G/' •rt r� DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) l� Receipt Human remains of % delivered on ;' , 20 r .a Pine View Cemetery Representing the funeral home named on burial permit , Official Funeral Directors Reg.or License#