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Bennett, Carolyn Marie 071111h1/4 q NEW YORK STATE DEPARTMENT OF HEALTH Burlap - Transit Permit Bureau of Vital Records Name First Middle Last Sex Carolyn Marie Bennett Female Date of Death Age If Veteran of U.S.Armed Forces, 12/31/2021 75 Years War or Dates F— Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town • Street Address Fort Hudson Nursing Center Inc pManner of Death © Natural Cause 0 Accident ❑Homicide 0 Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title G Eric Santell NP Address 319 Broadway, Fort Edward Town, New York 12828 Death Certificate Filed District Number Register Number City,Town orl/iltage Fort Edward 5755 74 Burial Date Cemetery,Crematory or Facility Name 01/05/2022 Pine View Crematory Entombment Address Cremation Queensbury Town,New York ElDonation ❑Removal Date Place Removed and/or and/or Held ~ t� Hold Address 0 a. Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/04/2022 Registrar of Vital Statistics Aimee£ Mahoney(E(ectronicaCCySigned) (signature) District Number 5755 Place Fort Edward, 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 C tZZ Place of Disposition ddress) W CC CC (section) d(lot number/ (grave number) SName of Sexton or Person in Charge of Premis .�tfi Z (p1 e print) /� ,, W g Si nature ��' Title G 1 M(, DOH-t555(07/t8)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of i delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#