Bennett, Norma NEW YORK STATE DEPARTMENT OF HEALTI� # MI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Norma Jean Bennett Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/14/2011 79 years War or Dates
Place of heath Hospital, Institution or
Z City, To .- Street Address
l Manner ofDeA- l'�• Glens Falls Glens Falls Hospital
a 111 natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
ILICircumstances Investigation
La Medical Certifier Name Title
II
Addreancy D. Carney M. D.
Warrensburg Health Center Warrensburg, NY
Death Certificate Filed District Number Register Number
City, Tovityfiliftexy Glens Fails 5Rn1 129
Mi ❑Burial Date Cemetery or Crematory
❑Eftombment Address03/16/2011 Pine View Crematorium
❑Cremation Oiieenshury, NY 12804
Date Place Removed
2❑Removal and/or Held
and/or Address
0 Hold
in
0 Date Point of
poi ❑Transportation Shipment
G by Common Destination
Sii Carrier
•
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
';) Name of Funeral Home Miller Funeral Home 01222
Address
35 Main Street Indian Lake. N Y 12842
Name of Funeral Firm Making Disposition or to Whom
fif Remains are Shipped, If Other than Above
,'; Address
lU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/16/2011 Registrar of Vital Statistics 3 cx kirca- 3j_t
(sign re)
ilig District Number Place
5601 Glens Falls
,.:.iii;: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E. 'p
III Date of Disposition 3-‘ II Place of Disposition ?w,r Y i2t,! Cre"%4 a sot.
2 (address)
ILA
0
ix (section) (lot n ber) (grave number)
Ci Name of Sexton or Person in Charge f Premises 71Arkufkr .mac•tacit"
Z (please print)
Signature (J' k' Title Met%)Mpfl..
(over)
DOH-1555 (02/2004)