Bennett, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH 4 21
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dorothy Eleanor Bennett Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 21,2011 84 War or Dates
Place of Death Hospital, Institution or
: City, Town or Village Glens Falls Street Address Glens Falls Hospital
dManner of Death X Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
C3.
Circumstances Investigation
w Medical Certifier Name Title
0 Suzanne Rayeski
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 '2 -1,5
❑Burial Date Cemetery or Crematory
Entombment May 23,2011 Pine View Crematory
Address
Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
Hold
V)
O Date Point of
NTransportation Shipment
by Common Destination
Carrier
I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home 00040
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
5' Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ,5 / Z '-1 1 1 I Registrar of Vital Statistics l�J C-"J- —Q, W
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 5 -ic-q Place of Disposition f niUINi Cr'rroozeonvti.
2 (address)
N
(section) Fnumbei (grave number)
pName of Sexton or Perso in Charge f Premises C r,sic., ,- hr1Gr'
ase print)
W I
Signature Title Car-p+r}i
(over)
DOH-1555 (02/2004)