Bennett, Charles NEW YORK STATE DEPARTMENT OF HEALTH E . �6
Vital Records Section ? Burial - Transit Permit
▪ Name First Middle Last Sex
Charles Ernest Bennett Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 22, 2014 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death DI Natural Cause 0 Accident El Homicide IEI Suicide riUndetermined IT Pending
Circumstances Investigation
i]k.: Medical Certifier Name Title
Suzanne Blood, Dr.
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number ow I Reg r Jumber
City, Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
August 27, 2014 Pine View Crematory
.'0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
• and/or
Hold Address
Date Point of
❑Transportation Shipment
by Common Destination
• Carrier
&ma Date Cemetery Address
g; 11 Disinterment
`• '0 Reinterment Date Cemetery Address
iii Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Ar. le NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains descr"vi boy?
sa ated.
Date Issued oedyilay Registrar of Vital Statistics
� (signature)
.ell District Number 5-IAD/ Place G l,4,L 51 6p/4 iJi'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/27/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) 1lot number) (grave number)
Name of Sexton or Person in Charge of Premises F'�r,,{ c., 1,
/l g (ple se print)
Signature AL A ..- Title CI' Al"
(over)
DOH-1555 (02/2004)