Wells, Lloyd NEW YORK STATE DEPARTMENT OF HEALTH `
Burial - Transits ermit
Vital Records Section
Name First Middle Last Sex
LLOYD B WELLS MALE
Date of Death Age If Veteran of U.S.Armed Forces,
• 03/04/2013 78 War or Dates
Place of Death Hospital, Institution
• City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
t. Manner of Death ® Natural Li Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Cause Circumstances Investigation
Medical Certifier Name Title
YEFIM YUSHVAYEV-CAVALIER DO
Address
43 NEW SCOTLAND AVE., ALBANY NY 12208
Death Certificate Filed District Number 1 Register Number
1 City,Town or Village City of Albany 101 462
Date Cemetery or Crematory
y ❑ Burial 03/05/2013 PINE VIEW CREMATORY
❑ Entombment Address
} Cremation QUEENSBURY, NY
`di. Date Place Removed
g Removal and/or Held
❑ and/or Address
N Hold
Date Point of
i. Transportation Shipment
❑ By Common
Destination
Carrier
, ❑
Disinterment Date Cemetery Address
A._
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. KILMER F.H. 01078
Address
136 MAIN ST., S GLENS FALLS NY 12803
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human remains de ribed above as indi ted. 1 ti
Date 03/05/2013 Registrar of Vital Statistics n'``�.R l �-4 ' .
Or
Issued (signature)
or-
p; 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:
li Date of Disposition 3-6-t Place of Disposition Rvttlk4J otKO..
U (address)
'Ui
(section) (lot number) (grave number)
viE Name of Sexton or Person in Charge of Pr mises ,3 nreit-
(please print)
Signature Title rt1trat,
(over)
DOH-1555 (02/2004)