Bennett, Ann Jane ,
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
a Name First Middle Last Sex
Ann Jane Bennett Female
Date of Death Age If Veteran of U.S.Armed Forces,
b2/14/2023 95 Years War or Dates
H Place of Death. Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W Manner of Death Undetermined Pending
� Natural Cause Accident 1:1Homicide Suicide g
W Circumstances DInvestigation
W Medical Certifier Name Title
Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 86
Burial Date Cemetery,Crematory or Facility Name
04/20/2023 St.Alphonsus Cemetery
F]Entombment .-Address _
❑Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
W
Hold Address
O
W❑Transportation
Date Point of
p by Common Shipment.
Carrier Destination
- c
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
t; Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
p- Remains are Shipped,If Otherthan Above
Address
cc
W - — - - - — — - - — - - - --- - -- - -- —
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/15/2023 Registrar of Vital Statistics Megan Wolin(ECectronicaCCy 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:
tJV Date of Disposition � 2 Place of Disposition �
2 (address)
W 1
(sedion) A umber) (gravenumber)
6 Name of Sexton or P son in Charge of Premises AT
ram'
Z (please print)
pl Signature Title
DOH-1555(07/18)p i of 2