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Wells, Loren A 1 /oc3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records ' Name First Middle Last Sex Loren A.Wells Male Date of Death Age If Veteran of U.S.Armed Forces, 12/07/2021 90 Years War or Dates i_ Place of Death Hospital,Institution or WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital p Manner of Death © Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined El Pending W U Circumstances Investigation W Medical Certifier Name Title CI Timothy Waters DO Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 714 ❑Burial Date Cemetery,Crematory or Facility Name 12/08/2021 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held H Hold Address U) 0 Date Point of U) 11 Transportation Shipment Q by Common Carrier Destination El Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom 1.. Remains are Shipped,If Other than Above $ Address Er U.I 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/08/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— WDate of Disposition l2Ito Ili Place of Disposition (address),,— 4 ri. - W CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pre ises (14 �4rt id (p ase print) W Signature g Title DOH-1555(07/i8)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on ' , 20 Pine View Cemetery Representing the funeral home named on_burialmit Official Funeral Directors Reg.or License#