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Benson, Jeffrey Leonard
1 IZsl K NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffrey Leonard Benson Male Date of Death Age If Veteran of U.S.Armed Forces, 11/24/2020 62 Years War or Dates E Place of Death Hospital,Institution or ILI Z City,Town or Village Castleton-on-Hudson Street Address Riverside Center For Rehabilitation And Nursing p Manner of Death ©Natural Cause 0 Accident 0 Homicide ❑Suicide Undetermined ❑Pending W U Circumstances Investigation 0 Medical Certifier Name Title Roman Koldayev MD Address 90 N Main St,Castleton-on-Hudson,New York 12033 Death Certificate Filed District Number Register Number City,Town or Village Castleton 4124 21 EIBurial Date Cemetery,Crematory or Facility Name Entombment 11/30/2020 Pine View Crematorium Address 0 Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held N Hold Address 0 _ n- Date Point of Cl) ❑Transportation Eli Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped,If Other than Above Address CC W E' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/30/2020 Registrar of Vital Statistics Padraic Sean Ellis(E(ectronica((ySigned) (signature) District Number 4124 Place Castleton, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH Z Date of Disposition UU P.7i°I Z Place of Disposition F.,(1— 4—' W 2 (address) W Cl) CC (section) (loyJfrimbef) (grave number) 8 Name of Sexton or Person in Charge of mises t++ � N�� Z d (please pr t) LLJ Signature w Title ,wW'(nit DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) ' ' 014243 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial.permit Official Funeral Directors Reg.or License#