Wells, Patricia • - _ 4 4 (91
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Patricia Wells Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 19, 2013 58 War or Dates
I..,, Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death n Natural Cause n Accident 0 Homicide n Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Frances Bollinger
Address
161 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1 F .
❑Burial Date Cemetery or Crematory
❑Entombment November 21,2013 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
E Hold
Ui
O Date Point of
yn Transportation Shipment
p by Common Destination
Carrier
I I Disinterment Date Cemetery Address
Ei
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
CZ
4. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 t I z)• / i3 Registrar of Vital Statistics Lti CAA. _
(signature
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:
w Date of Disposition If-LZ-13 Place of Disposition 'tfc c1,..J t:rt,.cl'ar�-
W (address)
N
0 (section) //lot number) (grave number)
Z• Name of Sexton or Person in Charge of Premises ct r, nnd4-
W 74,_
(pleakIe print)
Signature /1"--- Title OZErnt ''.
(over)
DOH-1555(02/2004)