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Bennett, Michael M . 7 1 ,...cn'----'\ NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Michael M.Bennett Male Date of Death Age If Veteran of U.S.Armed Forces, 03/10/2023 69 Years War or Dates 1_, Place of Death Hospital,Institution or Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek W Manner of Death Natural Cause nAccident I n I Homicide nSuicide Undetermined El Pending W U Circumstances Investigation W Medical Certifier Name Title O Suzanne Barth PA Address 112 Ski Bowl Rd,Johnsburg Town, New York 12853 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 10 ElBurial Date Cemetery,Crematory or Facility Name 03/13/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York EI Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address N p O. Date Point of • N Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address 0 Reinterment Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 5 Address It W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/13/2023 Registrar of Vital Statistics Jean M Comstock(Electronically Signed) (signature) District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z lL Date of Disposition 3��;�Zj Place of Disposition �-- - 111 (address) W N (section) /�:lot number) (grave number) 0 0 `/ It Name of Sexton or Person in Charge of Prem' es Z (p e se print) IJJ Title `"itri Signature DOH-1555(07/18)p 1 of 2 016782 Public Health Law Sec. 4145(2b) Receipt I Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#