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Bennett, Terry Roland NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Terry Roland Bennett Male Date of Death Age If Veteran of U.S.Armed Forces, 12/01/2020 67 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital `p Manner of Death ©Natural Cause Accident El Homicide ❑Suicide ❑Undetermined Pending Circumstances Investigation W Medical Certifier Name Title CI Stephen Perazzelli MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 547 ElBurial Date Cemetery,Crematory or Facility Name 12/03/2020 Pine View Crematorium Entombment Address u Cremation Queensbury Town,New York ❑Donation z Removal Date Place Removed and/or and/or Held - Hold Address N 0 a Date Point of U) Li Transportation Q by Common Shipment Carrier Destination Date Cemetery Address Disinterment ❑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 H Remains are Shipped,If Other than Above 2 Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/03/2020 Registrar of Vital Statistics Roden Andrew Curtis(ECectronica1TySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition �2(�fl0 Place of Disposition (address) W N (section) number) (grave number) Name of Sexton or Person in Charge o remises L.t9L 5401 Z (pieaseint) W Signature +� Title �1� I "l/ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 1 258 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#