Bennett, Gwen Ellen LeBeau 7n
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gwen Ellen LeBeau Bennett Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/23/2021 54 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Indian Lake Town Street Address 8746 State Route 30, Indian Lake Town, New York 12812
p Manner of Death Natural Cause El Accident El Homicide Suicide Li
r Undetermined Pending
UCircumstances Investigation
Q Medical Certifier Name Title
Carl Turner Coroner
Address
1188 Main Street,Long Lake Hamlet,New York 12847
Death Certificate Filed District Number Register Number
City,Town or Village Indian Lake 2053 11
❑Burial Date Cemetery,Crematory or Facility Name
08/25/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
EiDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
5 Address
CC
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/25/2021 Registrar of Vital Statistics Julie A Clawson(Electronically Signed)
(signature)
District Number 2053 Place Indian Lake, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II—
WDate of Disposition g''01-6-•,2-1 Place of Disposition p,ht, rz.,/),Y
(address)
W
CE N
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Y �V,ttJ
Z (please print)
W Signature Title C,!'imq 6-
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 1 0
Receipt
Human remains of delivered on , 20
„Acne View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#