Bennett, Bruce 4=ii/7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bruce Arthur Bennett M
Date of Death 1 1 /1 8/2 01 4 Age 6 2 If Veteran of U.S. Armed Forces,
War or Dates
f-- Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital
W Manner of Death 0 Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
L1 Suzanne Bergin MD
Address
3767 Main Street, Warrensburg,NY 12885
Death Certificate Filed District Number Register NumbeL
City, Town or Village Glens Falls I ,50
❑Burial Date Cemetery or Crematory
11 /20/2014 Pineview Crematory
❑Entombment Address
[ICremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
.... and/or Address
t" Hold
GI
O Date Point of
oi ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date . Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01077
Address 123 Main Street, Argyle,NY 12809
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
• Address
II
a` Permission is h reb granted to dispose of the humart(emains d scribed bove as in• cated.
Date Issued // �j i Registrar of Vital Statistics L�,Y,�,
(signature)
District Number () / Place C
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
k
tt Date of Disposition / ,/K Place of Disposition AZ— 1/‘-i/ ,rc ei} "
W (address) /
ta
Cr 2 (section) (1 number) (grave number)
0
D Name of Sexton o er Charge of Premises ‘S ") r-'c-J/mod
Z ) A e p(pleasfri t
Signature ILI `// Title r z I1 .CZ� ' `
(over)
DOH-1555 (02/2004)