Wells, Florence Inez . �, # 31b
NEW YORKSTATE DEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle -- Last Sex
Florence Inez Wells Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/09/2022 97 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Hoosick Falls Village Street Address The Center For Nursing And Rehabilitation At Hoosick Falls
Manner of Death EI Natural Cause DAccident ❑Homicide Suicide ❑Undetermined Pending
W ❑
Circumstances Investigation
W Medical Certifier Name Title
G James Carroll MD
Address
21 Danforth St,Hoosick Falls Village,New York 12090
Death Certificate Filed Village Of Hoosick Falls District Number Register Number
City,Town or Village 4120 16
Burial Date Cemetery,Crematory or Facility Name
04/12/2022 Pine View Crematory
Entombment Address
Cremation Oueertsbuty Town,New York
Donation
Q❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
d Date Point of
fA❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped,If Other than Above
`S' Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/12/2022 Registrar of Vital Statistics lOWsi FirtrannrnigGctrtmicraQySrgxso9
(signature)
District Number 4120 Place Village Of Hoosick Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4/—/1-2e'"t2 Place of Disposition ?r)')Q..Vie- '1.4) CI.-fo-rvi e-X9 7 2 (adahFss)
W
CO (section/ ` l , (lot number) (gra ue number)
g Name of Sexton or Person in arge o remises Li,
(' '�'"n �� v4
(please print)
W Signature Title 6 st_p-,,ek. r� �7c ``
DOH4555(o7/18)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 pn burial permit
Official Funeral Directors Reg.or License# i