Benoit, John NEW YORK STATE DEPARTMENT OF HEALTH -011 It Zb
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Terry Benoit Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 9, 2013 69 War or Dates
Place of Death Hospital, Institution or
Lu City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ci Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined n Pending
Circumstances Investigation
W'' Medical Certifier Name Title
W
Darci Gaioth-Grubbs, Dr.
Address
_ 102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
January 9, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date I Place Rer loved
z ❑ Removal and/or Held
} and/or Address
F Hold Pine View Crematorium
Date Point of
- ❑Transportation Shipment
CO by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
LU
0. Permission is hereby granted to dispose of the human remains describ ab ve ind' .
Date Issued Q//040/3 Registrar of Vital Statistics
/ (signature)
District Number S60/ Place ,lls -,V (a-oJ
I certify that the remains of the decedent identified above w e disposed of in accordance with this permit on:
W Date of Disposition //Ii3 Place of Disposition //]/,L / 04°9-/
(address)
LLI+
(section) umber) (grave number)
0 Name of Sexton: Pe n in_C of Premises i+ (I �/ �
(please print)
W Signature 1 ? Title S,
(over)
DOH-1555 (02/2004)