Bentley, Diane NEW Y®RK STATE DEPARTMENT OF HEALTH
Vital Records'Section Burial - Transit Permit
Name First Middle Last Sex
Diane Mary Bentley Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 9, 2011 69 War or Dates
Place of Death Hospital, Institution or
Z4C-1tTown or Village Glens Falls Street Address 82 Orchard St.
p Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
W Circumstances Investigation
u Medical Certifier Name Title
Daniel Way,MD
Address
', PO Box 158 Indian Lake,NY 12842
D th Certificate Filed District Number Register Number_
6
Town or Village Glens Falls 5601 S�J
❑X Burial Date Cemetery or Crematory
— December 13, 2011 Pine View Cemetery
_ Entombment Address
❑Cremation Quaker Road, Queensbur , NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
H Hold
W
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home , 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
E Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i 2h l 2./1.1 Registrar of Vital Statistics LJ C .Al)"r-
(signa��
District Number 5601 Place Glens Falls •/( /c2 7/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 1 2/1 3/1 1 Place of Disposition Pine View Cemetery
2 (address)
Cl)W Horicon 42 A 1
W (section) (lot number) (grave number)
cl Name of Sexton or Person i are of Premises
9 Michael Genier
C
Z (please print)
W
Signature .e/rv‘,' — Title Superintendent
(over)
DOH-1555(02/2004)