Bentley, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffrey Frank Bentley Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/12/2018 72 Years War or Dates 1966-1968
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident 0 Homicide Ei Suicide riUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 345
❑Burial Date Cemetery or Crematory
07/16/2018 Pine View Crematory
['Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal - and/or Held
and/orAddress
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/16/2018 Registrar of Vital Statistics Rg6ertA Curtis(Efectronica((y Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ill,(I'1 Place of Disposition KU-4
(address)
(section) (ly�umber) S (grave number)
Name of Sexton or Person in Char a of Premises t fu ((ll�� u -it
Signature Title(pleasprint)
(over)
DOH-1555(02/2004)