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Bentley, Jacqueline G v ' * NEW YORK STATE DEPARTMENT OF HEALTHISO , , ,, Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jacqueline G.Bentley Female Date of Death Age If Veteran of U.S.Armed Forces, 02/01/2024 68 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Corinth Village Street Address 214 Palmer Avenue B, Corinth Village, New York 12822 w W Manner of Death EI Natural Cause Accident Homicide nSuicide Undetermined Pending V Circumstances Investigation W Medical Certifier Name Title CI George Siniapkin MD Address 604 Palmer Avenue,Corinth Town, New York 12822 Death Certificate Filed Town Of Corinth District Number Register Number City,Town or Village 4553 6 RBurial Date Cemetery,Crematory or Facility Name 02/02/2024 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held ~ Hold Address U) 0 a Date Point of U) Transportation p by Common Shipment _ Carrier Destination Date Cemetery Address Disinterment ❑Reinterment Date Cemetery Address 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 F— Remains are Shipped,If Other than Above 2 Address IIC a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/02/2024 Registrar of Vital Statistics Brenda L Peris(Electronically Signed) (signature) District Number 4553 Place Town Of Corinth I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 2I S of Place of Disposition -a.u4vJ4v `o6014 l ILI 2 (address) W NIZ (section) (lot number) (grave number) c, Name of Sexton or Person in Charge of Premises It.,, 1 (plea print) Z ] C'C MeTrat. IL Signature �.� Title DOH-1555(07/18)p id 2 Public Health Law Sec. 4145(2b) 41. Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#