Bennett, Floyd E. SR If 1121
,. k
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Floyd E.Bennett Sr. _ Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/19/2022 75 Years War or Dates 1967-1969
p.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
113
Manner of Death El Natural Cause Accident Homicide Suicide Undetermined Pending
CI Circumstances Investigation
W Medical Certifier Name Title
G Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 282
Burial Date Cemetery,Crematory or Facility Name
0 05/23/2022 Pine View Crematory
Entombment— Address
IICremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
- and/or and/or Held
CO- Hold Address
0
O. Date Point of
Transportation
by Common Shipment
Carrier Destination
Disinterment El
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
i.,. Remains are Shipped,If Other than Above
a Address
IX
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/23/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F- 2
Z. Date of Disposition 5 12 y i 7z Place of Disposition � LL_ 60t�
Ili
2 (address)
Ill
tO
CC (section) (lot number) (grave number)
Qz Name of Sexton or Person in Charge of Premises 74/Iik-
L ""dt
/p ase print/
ILI
Signature Title
afMifroc
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#