Wells, Robin 1I ..
NEW PORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ROBIN LEE WELLS F
Date 0of Death 2018 Age 52 + If Veteran of U.S. Armed Forces, NO
/ War or Dates
1- Place of Death ! Hospital, Institution or
WCity, Town or Village Albany Street Address Albany Medical Center
6. Manner of Death 174 Natural Cause ®Accident ❑Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
Q Renee Porter PA
Address
43 New Scotland, Ave. , Albany, NY 12208
Death Certificate Filed ' District Number Register Number
City, Town or Village Albany 101
Burial I Date ? Cemetery or Crematory
03/05/2018 Pine View Crematory
❑Entombmenti Address
Cremation I Queensbury, NY
Removal I Date Place Removed
ri / /
and/or Held
2 and/or Address
Hold
04
2 Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
t Date ` Cemetery Address
❑Reinterment
Permit Issued to , Reoist8r2 ion Number
Name of Funeral Home Wilcox & Regan1
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
{ Address
a
Permission is hereby granted to dispose of the human re e 'be ove as indicated.
Date Issued Registrar of Vital Statistics-(r:-.-
s n
Distract Number 0► O I Place C,i / O .- A- I b &A y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f�
tV Date of Disposition 3 J S i►$ Place of Disposition ,� ,� Li�-.
2 (address)
V
fE (section) /1,11,(lot nv�r) (grave number)
QName of Sexton or Person ip Charge of Premises . 3%.siP
Z /f (please army .
14.1 Signature !!" �L.�1 Title film 1
(over)
DOH-1555 (02/2004)