Benway, Carol NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol A Benway Female
Date of Death Age If Veteran of U.S. Armed Forces,
2/ 11 45 years War or Dates
} Place0 of Dea/2(�h Hospital, Institution or
Z ark To i .a- Street Address
•.+.XX Clcns F Pack St Glens Fall$, N Y 12801
0 o, .nner eath AN Natural Cause D Accident ❑Homicide Suicide ❑Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
P.
Pa l Bac an Coroner
Address
Warrensburg Health Center, Warensburg, NY
Death Certificate Filed District Number Register Number
Zt Towiodtketxx Glens Falls c601 54
!I Bprial ate Cemetery or Crematory
❑Entombment 02/09/2011 Pineviaw cemetery
Address
❑Cremation __aiieenshilry, N Y
Date Place Removed
Removal and/or Held
and/or Address
E= Hold
ifi
0 Date Point of
❑Transportation Shipment
Et by Common Destination -
Carrier
iffil
'%i Q Disinterment Date Cemetery Address
pp
U lipReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01149
> Address
11 I afayette Street Oueensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom •
Remains are Shipped, If Other than Above
Address
rc
1
` Permission is hereby granted to dispose of the human emains described a ve as in• cated.
Date Issued 02/n7/2011 Registrar of Vital Statistics L% �. b� C7,
(signature)_
District Number Place
5601 Glens Falls/may /62P/
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
k
111 Date of Disposition 2/9/11 Place of Disposition Pine View Cemetery
2 (address)
Ili
Horicon 2C 2
IX (section) (lot number) (grave number)
ci Name of Sexton or Perso harge of Premises Michael Genier
(please print)
Signature �^�'`'' Title Superintendednt
(over)
DOH-1555 (02/2004)