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Wells, Royce NEW YORK STATE DEPARTMENT OF HEALTH a * Zz!S Vital Records Section Burial - Transit Permit Name First Middle Last Sex Royce E.Wells Male Date of Death Age If Veteran of U.S. Armed Forces, 03/15/2018 87 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ri❑Pending Circumstances Investigation Medical Certifier Name Title Jean Flanagan MD Address 319 Broadway, Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5755 11 El Burial Date Cemetery or Crematory 03/16/2018 Pine View Crematory ❑Entombment Address Cremation Queensbury Town, New York Date Place Removed • ElRemoval and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑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 Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/16/2018 Registrar of Vital Statistics Aimee Mahoney(Electronically Signed) (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: Date of Disposition air,lit Place of Disposition cm (address) (section) 4(lot number) (grave number) Name of Sexton or Person in Charge of Premises ( L e print Signature L f Title f ``r1itrt- (over) DOH-1555 (02/2004)