Loading...
Benack, Mary Lou NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mary Lou Benack Female Date of Death Age If Veteran of U.S.Armed Forces, 09/24/2021 78 Years War or Dates F' Place of Death Hospital,Institution or City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing p▪ Manner of Death ©Natural Cause ❑Accident 1=I Homicide I=1 Suicide ❑Undetermined ❑Pending W Circumstances Investigation UIJ Medical Certifier Name Title CI Shardul Koppar DO Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville Village 5725 49 ❑Burial Date Cemetery,Crematory or Facility Name 09/27/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury,New York ❑Donation Z Removal Date Place Removed and/or and/or Held H Hold Address CO a Date Point of U) ❑Transportation Shipment 5 by Common Carrier Destination Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom L Remains are Shipped,If Other than Above Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/27/2021 Registrar of Vital Statistics Wic(zard<Ruberts(EhctronicaCCy Signed) (signature) District Number 5725 Place Granville Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 61 I M.1 z1 Place of Disposition -F�lL, �r. t, a (address) W fr Q� (section) /!ot number/ (grave number) O Name of Sexton or Person in Charge of P ses (7, 14% `'' 1�µit z /pleas�int/ iJ! LlI Title (i'" Signature DOH-1555(07/18)pi of 2 t J 015182 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 • Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#