Wells, Dortha •
NEW YORK STATE DEPARTMENT OF HEALTH � J
Vital Records Section Burial - Transit Permit
x Name First Middle Last Sex
Dortha G. Wells Female
a: Date of Death Age If Veteran of U.S. Armed Forces,
F7 December 20,2013 67 War or Dates
'p. Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 45 Zenas Drive
_°< Manner of Death X Natural Cause ' Accident 'Homicide Suicide determineds
Pending
CircumstanceUn Investigation
te Medical Certifier Name Title
Robert W. Sponzo
E '_ Address
102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number R gister Number
[ City, Town or Village Queensbury 5657 I 1
❑Burial Date Cemetery or Crematory
0 Entombment December 23,2013 Pine View Crematory
Address
0 Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z —Removal and/or Held
and/or Address
H Hold
cn
0 Date Point of
N I ]Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
x Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human .
remains described ab "a as indicated.
l
Date Issued , Z31c0tegistrar of Vital Statistics C-�. � '�-�,
(signature)
District Number 5657 Place Queensbury
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z 1 (...tot,......
Date of Disposition i//ab1l3 Place of Disposition ,,,z( ��
W (address)
CO
Qo (section) (I num r) �` (grave number)
Name of Sexton or Person i Charge of P emises i,i r =..�\(_„.Jf
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W Signature L Title Ci2rrwt4!?Ji2
(over)
DOH-1555 (02/2004)