Bennett, Patricia f 3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Trans t ermit
Name First Middle Last Sex
Patricia Ann Bpnnptt FPma1P
Date of Death Age If Veteran of U.S. Armed Forces,
June 10, 2017 75 yrs . War or Dates no
1— Place of Death Hospital, Institution or
W City, Town or Village Fort Ann Street Address 52 Clay Hi11 Rd.
0 Manner of Death Natural Cause ❑Accident ❑Homicide D Suicide ri❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
o mfi?/{ gO Pm 4"/ n . a .
ss
/64 d709ek S'T 016NS F/1 6S;,v/ /aPo 1
Death Certificate Filed District Number Register Number
City, Town or Village Fort Ann 5754 Le2
❑Burial Date Cemetery or Crematory
DEntombment June 12r 2017 PinPViPw Crematorium
Address
®Cremation Queensbury, NY. 12804
Date Place Removed
Z Removal and/or Held
01-1
and/or Address
H Hold
N
O Date Point of
N ❑Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St. , P.O. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
g Address
W
C. Permission is hereby granted to dispose of the human remains described above indicated.
Date Issued June 12, 20 ijegistrar of Vital Statistics ' ' -/
(signature)
District Number 5754 Place Town of Fort Ann, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iLl Date of Disposition bOn Place of Disposition CAL tfka, 64**0(1.-N..
g (address)
W
f1)
r (section) j f,(lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises G/'r,) Sit
/ (pl ase print)
IA ;r, �
Signature �"'� Title
(over)
DOH-1555 (02/2004)