Bennett, Raymond Lee Sr. ( : . —TO
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Raymond Lee Bennett Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/15/2023 76 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Village Street Address 14 River Street, Fort Edward Village, New York 12828
w Manner of Death Undetermined Pending
Natural Cause Accident Homicide Suicide
LLJ
0 Circumstances Investigation
1iJ Medical Certifier Name Title
CI Robert Love MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 5
Burial Date Cemetery,Crematory or Facility Name
01/20/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
a Date Point of
(q❑Transportation Shipment
p by Common
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
- Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/17/2023 Registrar of Vital Statistics Aimee G Mahoney(ECectronicarry Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition I IZ317,3. Place of Disposition -
LV (address)
W
U) (section) I (iot number) �` (grave number)
c, Name of Sexton or Person in Char Premises L —�\LMl�n
(pie e print)
W Signature Title l lam'
DOH-1555(07/18)p 1 of 2
ti S f
Public Health Law Sec. 4145(2b)
Receipt
Human remains of _ delivered on , 20
1
IPine View Cemetery Representing the funeral home named on burial permit
1 Official Funeral Directors Reg. or License#