Bennett, Will L 5 3 S
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Will L.Bennett Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/26/2021 46 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Hadley Town Street Address Rockwell Falls,Hadley Town,New York 12835
p Manner of Death ❑ Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI Eugene Ladue Coroner
Address
31 Woodlawn Ave.,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Hadley 4558 13
❑Burial Date Cemetery,Crematory or Facility Name
07/01/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
Donation
g El Removal Date Place Removed "
and/or and/or Held
H Hold Address
0
O. Date Point of
co Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/30/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed)
(signature)
District Number 4558 Place Hadley, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition )— 1--� pr�l Place of Disposition O '�SJ 1,4, �C,,,I',�5 jf/
2 1 (address)
W
CC
N (section) (lot number) (grave number)
0
• Name of Sexton or Person in Charge of Premises Jam 11-j
(please print)
fJ
W Signature �y"h_C"4 Title (7�(.�,e►1E{itGr
DOH-1555 With)p i of 2 v
Public Health Law Sec. 4145(2b) 0 1490
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#