Wells, Wanda Jo NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle
Wanda Jo Wells Last Sex
Date of Death Female
Age If Veteran of U.S.Armed Forces,
06/17/2022 61 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 a Natural Cause
W nAccident Homicide ❑Undetermined Suicide ❑Pending
LU Medical Certifier Name Title Circumstances Investigation
0
Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number
City,Town or Village Register Number
5601 324
nBurial Date Cemetery,Crematory or Facility Name
ri06/21/2022 Pine View Crematory
Entombment -Address
Cremation Queensbury Town,New York
Donation
ElRemoval Date Place Removed
0E- and/or and/or Held
N Hold Address
0
a Date Point of
U) Transportation
CI Common Shipment
Carrier Destination
Date Cemetery Address
nDisinterment
Reinterment Date Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
1 - Remains are Shipped,If Other than Above
Address
CC
W
o. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2022 Registrar of Vital Statistics 9l1egan Notin(ECectronicalTySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
Z Date of Disposition (An(� Place of Disposition
W �N u� —
2 (address)
W
CC
(section) (lot num (grave number)
SO
Name of Sexton or Person in Charge of P mises i.• LrN�
ZV(please print)
W Signature Title (1?�!1'1 rte
DOH-1555(07/18)p 1 of 2
0 rr6 004
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
I
Pine View Cemetery Representing resenting the funeral home named on burial permit
Official Funeral Directors Reg.or License#