George, Herbert iit
NEW YORK STATE DEPARTMENT OF HEALTI-�L - 4t i2-3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Herbert Bennett Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 16, 2011 79 War or Dates
I-, Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death 0 Natural Cause Ell Accident 0 Homicide El Suicide riUndetermined ri Pending
ill
LI Circumstances Investigation
W Medical Certifier Name Title
Ci Gamal Khalify, NID
Address
Glens Falls, NY
Death Certificate Filed District Number Register hr J`1
City, 1c$ Glens Falls 5601 c._,=
❑Burial Date Cemetery or Crematory
December 19, 2011 Pine View Crematorium
❑Entombment Address
&C Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
o and/or Address
p Hold
0 Date Point of
Transportation Shipment
CO by Common Destination
CI Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
}—' Remains are Shipped, If Other than Above
Address
i -
lit
; Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued +Z.) l y J i , Registrar of Vital Statistics k.A)CJ-•1/41v,Q jam'`°' '
(signature)
h. District Number 5601 Place City of Glens Falls, NY
I certify that the remains of the decedent identified above were disposed fin accordance with this permit on:
F—'
W_ Date of Disposition pg tUl Z0q Place of Disposition r4'1)4ca Cltewat i0 .
(address)
Ui
(section) er (grave number)
g Name of Sexton or Person in Char of Premises I (lot numb
nsr Q N*��
Z (please print)
at Signature Title )C4 mK0L-
(over)
DOH-1555 (02/2004)