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Bennett, Gurney Grant 41/D NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gurney Grant Bennett Male Date of Death Age If Veteran of U.S.Armed Forces, 11/17/2021 71 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Hudson Falls Village Street Address 40 Mohican Terrace,Hudson Falls Village, New York 12389 p Manner of Death ©Natural Cause ❑Accident El Homicide ❑Suicide 0 Undetermined 0 Pending W Circumstances Investigation W Medical Certifier Name Title CI Rita All NP Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 34 ❑Burial Date Cemetery,Crematory or Facility Name 11/22/2021 Pine View Crematorium IDEntombment Address X❑Cremation Queensbury Town,New York ▪Donation Z ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 Q. Date Point of CD ❑Transportation Shipment G by Common Carrier Destination Disinterment Date Cemetery Address El 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 Remains are Shipped,If Other than Above "' Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/22/2021 Registrar of Vital Statistics Cynthia Bardin(ECectronicaCCy Signed) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F- Z Date of Disposition ii I Z7 Ili Place of Disposition 4"1/71.4111--- �„Jtdr--- W address) W CO (section) (lot number) �( (grave number) Q Name of Sexton or Person in Chpremises 1h l�� 1'f"1 z (pie se print) z W 0401„1j p� Signature l Title DOH-1555(07/18)p t of 2 1 - - p I 5 3 5 1 Public Health Law Sec. 4145(2b) IReceipt Human remains of delivered on_ , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#—