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Wells-Sartoris, Bentley ( .. , 675— NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Is Name First Middle Last Sex BENTLEY AUDLEY-THOMAS WELLS-SARTORIS MALE Date of Death Age If Veteran of U.S.Armed Forces, 09/22/2016 3DAYS War or Dates NO #E--: Place of Death Hospital, Institution City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER W Manner of Death Natural Undetermined Pending ® ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑ Cause Circumstances Investigation Medical Certifier NameIii Title p MEREDITH MONACO-BROWN MD Address 43 NEW SCOTLAND AVE ALBANY NY 12208 Death Certificate Filed District Number Register Number K City,Town or Village City of Albany 101 1965 Date Cemetery or Crematory ❑ Burial 9/27/2016 PINE VIEW CREMATORIUM ❑ Entombment Address ® Cremation QUEENSBURY, NY Date Place Removed Z Removal and/or Held 0' ❑ and/or Address F- Hold © Date Point of a Transportation Shipment ? ❑ By Common Destination C/ Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued To Registration Number Name of Funeral Home CARLETON FH INC 00281 Address 68 MAIN ST. HUDSON FALLS NY 12839 Name of Funeral Firm Making Disposition or to Whom N Remains are Shipped, If Other than Above 21 Address rt d Permission is hereby granted to dispose of the human remains dparibe above as indicated Date 9/26/2016 ca— Registrar of Vital Statistics --, l c&J) 0 Issued (signat e) District Number 101 Place City of Albany, NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z'' Date of Disposition II ZSf IL Place of Disposition giadit..#4 £ ,ct*r4^... I; (address) w w (section) zil(lot number) (grave number) CI Z' Name of Sexton or Person in Charge of Premises rif s 1#r S Old tit Ili' (please print) / r, Signature L ( * Title (DEP1►f'OL (over) DOH-1555 (02/2004)