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Wells, Peggy \II° NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Peggy Wells Female Date of Death Age If Veteran of U.S.Armed Forces, 12/21/2021 82 Years War or Dates Place of Death Hospital,Institution or z City,Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death W Undetermined Pending©Natural Cause Accident Homicide Suicide Circumstances Investigation WMedical Certifier Name Title 0 Sean Bain MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 624 ❑Burial Date Cemetery,Crematory or Facility Name 12/27/2021 Pine View Crematory El Entombment Address iCremation Queensbury Town,New York EiDonation OZ ❑Removal Date Place Removed and/or and/or Held ~ Hold Address N O a Date Point of (/) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom — Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/27/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition � 'a��j2( Place of Disposition P; foe �i� � Cre� 4)� IJJ (address) W N (section) (lot number) (grave number) CCv i1 GName of Sexton or Person in Charg of Pr mi' s N 1� IQ 7�YIU.^> Z (please print) W Signature Title Q +01^' g �- DOH-1555(o7/t8)p i of 2 tom. Public Health Law Sec. 4145(2b) Receipt 1 Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License# ,•'