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Bennett, David Edward wig NEW YORK STATE DEPARTMENT OF HEALTH %II Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David Edward Bennett Male Date of Death Age If Veteran of U.S.Armed Forces, 07/28/2023 55 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 7 Adams Road,Moreau Town, New York 12803 W Manner of Death (�Undetermined Pending G Natural Cause Accident Homicide Suicide W Circumstances Investigation U Title all Medical Certifier Name Ci Darci Gaiotti-Grubbs MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 41 ElBurial Date Cemetery,Crematory or Facility Name 07/31/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation o CI Removal Date Place Removed and/or Held t and/or usHold Address 0 Date Point of Cl)❑Transportation Shipment CQ by Common Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address ElReinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F.. Remains are Shipped,If Other than Above 5 Address IX W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/31/2023 Registrar of Vital Statistics Brenda 9futter(Electronically Signed) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition f-).-Zv 23 Place of Disposition ?i A e jf;eaL) Cr e,s j sr. NY 2 (address) W NCC (section) (lot number) (grave number) G Name of Sexton or Person in Charge o , remis /�l4 7�lDi✓ 1�0 7 (please print) UJ Signature it-1 Title -erk-4-40-4— 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 bur-iyal-permit Official Funeral Directors Reg.or License#