Wells, Margaret 07
NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section . let Burial - Transit Permit
Name First Middle Last Sex
Margaret A Wells Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/18/2015 73 years War or Dates
f4 Place of Death Hospital, Institution or
W City, TdCXXilt 10014tX Glens Falls Street Address Glens Falls Hospital
ciManner of Death 0 Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
13 Amy Hogan- Moulton M D
Address
2 Broad Street Plaza Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number ,
City, ToW( dk 441WiroX Glens Falls 5601 92
❑Burial Date Cemetery or Crematory
02/19/2015 Pine View Crematorium
❑Entombment Address
[Cremation Queensbury, NY 12804 .
Date Place Removed
Z. ❑Removal and/or Held
2 and/or Address;
Hold
0 Date Point of
tili ID Transportation Shipment
L by Common Destination
Carrier
❑_Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
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
2 Address
i
III .
Permission is hereby granted to dispose of the human remains desc 'bedabov as i ted.
ii Date Issued 02/18/2015 Registrar of Vital Statistics , �
____ ret
(signature)
District Number 5601 Place Glens Falls
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Zr
ll Date of Disposition Z 1i5hhrr Place of Disposition 'tt�u�,,� C,..,,„. j,-...
2 (address)
LU
Crtfl
(section) /(lot n tuber) (grave number)
pName of Sexton or Person in Char a of Premises �rl eliStr-
Z
(please print)
ILI Signature Title eli6 ry
(over)
DOH-1555 (02/2004)