Bennett, Michelle Gertrude 4111
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michelle Gertrude Bennett Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/05/2022 53 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 492 Glen Street,Glens Falls,New York 12801
,p Manner of Death Li
Natural Cause Accident Homicide Suicide ❑Undetermined NI Pending
Circumstances Investigation
G Medical Certifier Name Title
Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 84
ElBurial Date Cemetery,Crematory or Facility Name
02/08/2022 Pine View Crematory
El Entombment Address
IDCremation Queensbury,New York
ElDonation
Z Date Place Removed
0 El Removal
L and/or and/or Held
N Hold Address
2.
to ❑Transportation
Date Point of
a by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
.2 Address
CC
W
Cti Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/08/2022 Registrar of Vital Statistics Megan Wolin(ECectronicallySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 'a--ct-1 y f Place of Disposition ie.) ittU Gfc_,fhdoly
2 (address)
W
U)
8 (section)
(lot number) (grave number)
Name of Sexton or Person in Charge of Premises ��6 vn�,Y �`�i��S
Z (please print)
W Signature ',eiUm�c f-( Title C.,r-AC 'r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) °` `� "
Receipt
Human remains of t delivered on , 20
Vine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#