Wells, Raymond NEWYORKSTATEDEPARTMENTOFHEALTH •
It s31
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Raymond Wells Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/07/2022 80 Years War or Dates
1... Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address 20 Elm Street 412,Glens Falls,New York 12801
Q Manner of Death El Natural Cause Accident ri Homicide Suicide Undetermined ❑Pending
11)
0 Circumstances Investigation
LLI 0 Medical Certifier Name Title
John Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
" Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 _ 356
Burial Date Cemetery,Crematory or Facility Name
IINNMI 07/08/2022 Pine View Crematory
Entombment Address —
IIICremation Queensbury Town,New York
Donation
cl 0 Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Q. Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
�. Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
N Address
OC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/08/2022 Registrar of Vital Statistics Megan Wolin(ECectronicairySigned)
/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 pe"rym�it on:
WIN `t i
Date of Disposition 118 l it Place of Disposition
2 (address)
W
N
OC (section) A
(!ot numbel � (grave number)
GName of Sexton or Person in Char of Premises � he4
lease print)
Ill Signature Titleare-4Vn rase
DOH-1555(o7/t8)p i of 2
n
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#