Bennett, Paul NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle EdwardLast Sex
aul Edward i ennett Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/14/2015 78 years War or Dates
1- Place of Death Hospital, Institution or
W City, Tc�Wrr & Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
IL/ Circumstances Investigation
W Medical Certifier Name Title
Q Noelle Stevens M D
Adlib�sbroad Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TaGXr 4 Glens Falls 5601 304
❑Burial Date Cemetery or Crematory
06/16/2015 Pine View Crematorium
❑Entombment Address
QCremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
1.= Hold
O Date Point of
05 ❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
•
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01821
Address
11 Alqonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above •
• Address
#r
It
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/15/2015 Registrar of Vital Statistics .
(signa ure)
District Number 5601 Place Glens Falls
I}-: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILLi Date of Disposition (, I I l K Place of Disposition Pi,U,, ) C w./`-.
2 (address)
LU
Cl)
CC (section) A(lot number) (grave number)
DName of Sexton or Person in Charge of Premises c Sbv4i�
2 (pl se print)
tJ Signature16—
Title fi ""nk
(over)
DOH-1555 (02/2004)