Bennett, Regina Coeli ld )Z.
NEW YORK STATE DEPARTMENT OF HEALTH , Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Regina Coeli Bennett Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/29/2020 33 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 33 Third Street,Glens Falls,New York 12801
11.1
p Manner of Death 0 Natural Cause D Accident ❑ Homicide Suicide Undetermined 1=1Pending
BJ Circumstances Investigation
W Medical Certifier Name Title
Maeve Dargush NP
Address
43 New Scotland Avenue MC7,Albany,New York 12203
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 442
❑ Burial Date Cemetery,Crematory or Facility Name
10/01/2020 Pine View Crematory
❑ Entombment Address
X❑Cremation Queensbury Town,New York
ElDonation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
0
CL Date Point of
U) Li Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
4 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/01/2020 Registrar of Vital Statistics *th-ert/?ndrewCurt&(E1'ctronicall;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:
IH
Z Date of Disposition /0/I/ ?O Place of Disposition � AC"---
11.1
2 (address)
W
U)
(section) A (lot numb (grave number)
Name of Sexton or Person in Charge of Pre s r' Ql hM��
Z lease print
UJ Signature Title ( '
DOH-1555(o7/18)p i of 2
014064
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#