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Wells Jr., Naylor 14 sq4 NEW YORK STATE DEPARTMENT OF HEALTH INN Vital Records Section , - Burial - Transit Permit Name First Middle Last Sex Naylor R. Wells,Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, July 19,2018 63 War or Dates Place of Death Hospital, Institution or City, Town or Village Warrensburg Street Address 267 State Route 28 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title ' Christopher Mason Address 102 Park St.,Glens Falls,NY 12801 Death Certificate Filed j District Number Register Number City, Town or Village Warrensburg ' 5660 ❑Burial Date Cemetery or Crematory July 23,2018 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or I Address Hold 1 U) O Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom t- Remains are Shipped, If Other than Above 2 Address re Wa.; Permission is h reby ranted to dispose of the human r ins d cri ed above as indicated. Date Issued 3 Registrar of Vital Statis (signature) District Number 5660 Place Warrensburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 74,1.4 It? Place of Disposition pf� 0 ,�,,, Gr'e,rict IcrY W I (address) U) (X (section) (lot number) (grave number) pName of Sexton or Person in Charge of Premises c-C,cln^csr if i5 L (please print) W Signature %/' Title �i{�Ni rt or (over) DOH-1555 (02/2004)