Bennett, Skylar NEW YORK STATE DEPARTMENT OF HEALTH (-(4
Vital Records Section r ' Burial - Transit Permit
Name First Middle Last Sex
Skylar MScott Bennett Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/19/2015 9mons13days War or Dates No
Place of Death Hospital, Institution or
W City, Town or Village Al bany Street Address Albany Medical Center Hospital
0 Manner of Death Llim Natural Cause �Accident Homicide �Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
Walter Edge MD
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Reggister Number
City, Town or Village Al bany 101 1321
❑Burial Date Cemetery or Crematory
06/22/2015 I Pine View Crematorium
i ❑Entombment Address
gS['Cremation Queensbury, New York
Date Place Removed
Z n Removal and/or Held
and/or
� Address
Cl)
Hold
O Date Point of
t0 Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to R i tration Number
Name of Funeral Home .Carleton Funeral Home, Inc. 00Z81
Address
68 Main Street 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
it
1f
` Permission is hereby granted to dispose ot.th.e human remains described abo as indic
Date Issued 06/22/2015 Registrar of Vit is ,N)s_e ;
(sig e) ..
iiig District Number 101 Place City of Al bany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lil Date of Disposition (0-4s- iS Place of Disposition r',,lev;P ) Cr,e y,.,44 or,
2 (address)
ILI
U)
Cr (section) / (lot number) (grave number)
tt Name of Sexton or Person in Charge of Premises I ofky t`vn-eue.,
Z (please print)
4l
ta
Signature4 Title CfeN,a.40r1, P5-1 '
(over)
DOH-1555 (02/2004)