Wells, Scott NEW YORK STATE DEPARTMENT OF 3
Vital Records Section Burial - Transit Permit
Name First -, 1 Last Sex
Scott -ichard Wells Male
Date of Death A• Veteran of U.S. Armed Forces,
November 27, 2018 57 War or Dates
8 Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 19 North Oak Street
W Manner of Death Xi Natural Cause ❑ Accident El Homicide I:] Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 John Stoutenburg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village S7 „ (,
❑Burial Date Cemetery or Crematory
k' November 29, 2018 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
} Hold
f? Date Point of
per, ❑Transportation Shipment
co by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
— El Reinterment Date Cemetery Address
Permit Issued to Registration Number
,;' Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
:. Name of Funeral Firm Making Disposition or to Whom
I-= Remains are Shipped, If Other than Above
2: Address
I
W
t1, Permission is hereby granted to dispose of the human rema' described above as indicated.
Date Issued //ug9•,/G/g Registrar of Vital Statistics c, , Lv cat_l_ -�
(signature)
District Number 6 ?d C, Place .J s c ,a,,.`` n c o __, •
t:' I certify that the remains of the decedent identified abovwere disposed of in accordance with this permit on:
Date of Disposition 11/29/2018 Place of Disposition Queensbury,NY 12804 Vew �,tz./►4tztY
2 (addfipk,
ss)
W Wells
' (section) (lot number) (grave number)
g. Name of Sexton or Person in Charge of Premises Te_ir'1 e,Y Stv,;r-4.5
Tease print)
W, Signature i/ . _.• Title Gr�rn�
/rti" w
(over)
DOH-1555 (02/2004)