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Bennett, Marilyn ANNE • NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Marilyn Anne Bennett Female Date of Death Age If Veteran of U.S.Armed Forces, 12/16/2021 67 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Valatie Village Street Address Barnwell Nursing And Rehabilitation Center W Manner of Death G © Natural Cause EI Accident 1=1 Homicide 1=1 Suicide I=1 Undetermined Pending W Circumstances Investigation uW• Medical Certifier Name Title Kathleen Steiger NP Address 3230 Church St,Valatie Village,New York 12184 Death Certificate Filed District Number Register Number City,Town or Village Valatie Village 1023 81 Burial Date Cemetery,Crematory or Facility Name 12/18/2021 Pine View Crematory ❑Entombment Address 1 Cremation Queensbury Town,New York 0 Donation Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Li Date Point of p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom F. Remains are Shipped,If Other than Above a Address W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/18/2021 Registrar of Vital Statistics Barbara Ann Tischer(ECectronicalTySigned) (signature) District Number 1023 Place Valatie Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition (2.120 I ,�,Place of Disposition .. e_hn 2 (address) W CC N (section) (lot number) (grave number) • Name of Sexton or Person in Char a of Premises �r,� l� �,v�r Z (ple print) �^ W Signature Title L DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt ; 1 + Human remains of '" " delivered on , 20 } Pine View Cemetery Representing the funeral home namedlon b�tri4„permit Official Funeral Directors Reg.or License# w'