Bennett, Keri M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
- Keri M.Bennett Female
. Date of Death Age If Veteran of U.S.Armed Forces,
03/18/2022 41 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Bolton Town Street Address 38 Horicon Avenue,Bolton Town,New York 12814
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0 Manner of Death (� Undetermined X Pending
El Natural Cause Accident I I Homicide Suicide
iw Circumstances Investigation
Medical Certifier Name Title
1.3 Timothy Murphy Coroner
14 Address
52 Haviland Avenue,Glens Falls,New York 12801
.f Death Certificate Filed Town Of Bolton District Number Register Number
' City,Town or Village 5650 2
Burial Date Cemetery,Crematory or Facility Name
03/28/2022 Pine View Crematory
rq Entombment
Address
-t Cremation Queensbury Town,New York
Donation
Z Date Place Removed
Removal and/or Held
and/or
fr
Hold Address
EL Date Point of
COTransportation Shipment
p by Common
Carrier Destination
li
,r Date Cemetery Address
❑Disinterment
�', Date Cemetery Address
„❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
,= Address
=gib 3809 Main St,Warrensburg,New York 12885
,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
LC1
411
t Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/22/2022 Registrar of Vital Statistics Jodi Petteys(ECectronicatty Signed)
4? (signature)
District Number 5650 Place Town Of Bolton
h,T
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tZtl /a
Date of Disposition 11 t$ 122 Place of Disposition 'M dd�ressl � cJ~Ulf
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CO
CC (section) (tot number) (grave number)
Name of Sexton or Person in Charge of Premises /7•j ''"' i
ce''"MI It/p/ se print)
Signature L/ Title EMATO(L
DOH-1555(o7/18)p i of 2
"'") 1 c ./
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ''j. delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#