Bennett, Anna NEW YORK STATE DEPARTMENT OF HEALTH
Vital ReCrds Section Burial - Transit Permit
Name First Middle Last Sex
Anna F. Bennett Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 23, 2013 99 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address The Pines
Manner of Death 0 Natural Cause ❑ Accident I I Homicide Ei Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof, M.D. Dr.
Address
100 Broad Street Glens Falls, NY 12801
': . Death Certificate Filed District Number Register Number
gkv City, Town or Village
'` ®Burial Date Cemetery or Crematory
. ❑ April 20, 2013 West Glens Falls Cemetery
,a Entombment
3" Address
❑Cremation Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
,
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
'r,4❑ Reinterment
Date Cemetery Address
.h Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
.` Remains are Shipped, If Other than Above
Address
Permission ish by ranted to dispose of the human ains described ab e as indicated.
Date Issued 7` / �� Registrar of Vital Statisti
N.
_...----- ,ii:mot, District Numb 755` Place ,-j ," r/ f,-46,�cign re)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/20/2013 Place of Disposition Queensbury,NY 12804
(address)
West Glens Falls Cemetery
(section) (lot number) (grave number)
Name of Sextcon or Person in Charge of Premises Connie L. Goedert
(please print)
Signature---` '�- J Title Super i ntendent
(over)
DOH-1555 (02/2004)