Wells, Maurice NEW YORK STATE DEPARTMENT OF HEALTH """.I Z3 o
Vital Records Section _ Burial - Transit Permit
iV Name First Middle Last Sex
Maurice A. Wells Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/02/7M11 69 years War or Dates
144 Place of Death Hospital, Institution or
fi City, Tow it Street Address
J7C a'- X GIPns Falb Glens Falls Hospital
12 Manner of Death 17,/ ltural Cause ❑Accident El Homicide Suicide Undetermined 0 Pending
It Circumstances Investigation
8 Medical Certifier Name Title
0 Nancy r7 (.nrnPy M. D.
Address
Warrensburg Health Center Warrensburg, NY
Death Certificate Filed District Number Register Number
City, TowTomtitlyillaavraStXX Glens Falls 5601 206
II❑Burial Date Cemetery or Crematory
❑Entombment Q5/l13/2011 Pine View Cemetery
Address
NC emation Queensbury. NY 12804
Date Place Removed
Z ❑Removal and/or Held ,
and/or Address
f= Hold
0 Date Point of
6,0 Transportation Shipment
. by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01136
Address.
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
Permission is hereby granted to dispose of the human remains descrri, ed above s in ' t .
Date Issued 05/03/2011 Registrar of Vital Statistics i�U ;.•--&
signature)
Nii District Number 5601 Place Glens Falls
`.; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lil Date of Disposition S -14-t( Place of Disposition ,,4 Ull✓ C (Or iv...
(address)
IIEI
Cl)
IX (section) , (lot numb r) (grave number)
Name of Sexton or Pe son in ChaFg f Premises Z :.r tfiler• {"%Nit
(please print)
til
Signature t -t Title 0247 in vjw a
•
(over)
DOH-1555 (02/2004)