Wells, Brigitte s
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
fe Name First Middle Last Sex
Brigitte Eliesabeth Wells Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/03/2018 84 Years War or Dates
Place of Death Hospital, Institution or
"' City, Town or Village Granville Town Street Address The Orchard Nursing And Rehabilitation Centre
Manner of Death f Natural Cause ❑Accident ❑Homicide E Suicide ❑Undetermined ❑Pending
i. Circumstances Investigation
Medical Certifier Name Title
Jennifer Hayes MD
Address
10421 State Route 40,Granville Town,New York 12832
VC
Death Certificate Filed District Number Register Number
City, Town or Village Granville 5756 18
ktfi,❑Burial Date Cemetery or Crematory
06/07/2018 Pine View Crematory
oN❑Entombment Address
"®Cremation Queensbury, New York
Date Place Removed
Removal 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
ki Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
kri 407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
_- Address
Es
cia
Permission is hereby granted to dispose of the human remains described above as indicated.
1 Date Issued 06/07/2018 Registrar of Vital Statistics Jenny Linda Martefle(E(ectronically Signed)
(signature)
, District Number 5756 Place Granville, New York
''' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IT, Date of Disposition &it II g Place of Disposition k;ki•.✓ fr.Licf
--� (address)
se (section) /i lot number) r. (grave number)
Name of Sexton or Person in Charge of Premises [ 9N 1- 3oA
frif
(plese print)
Signature 4 Title /4111/0—
(over)
DOH-1555(02/2004)