Monty Jr., James NEW YORK STATE DEPARTMENT OF HEALTH ell" 1
it 1(72
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James K. Monty Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
1. June 12, 2017 55 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Home 1i-le
G Manner of Death Natural Cause El Accident El Homicide El Suicide ❑Undetermined u Pending
W Circumstances Investigation
0 Medical Certifier Name Title
Ill Dr. N Balasnbramaniary, M.D. Dr.
0 Address
Albany Medical Center, Albany, NY 12201
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 57)-g 9
0 Burial Date Cemetery or Crematory
June 20, 2017 Pineview Crematorium
❑Entombment Address
m �Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
and/or Address
�' Hold
0 Date Point of
0 El Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
ir Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued f I I q 101d 11 Registrar of Vital Statistics a_ nutum
(signature)
District Number Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition 06/2$/2017 Place of Disposition Pineview Crematorium
2 (address)
0
0 (section)) (lot umber) (grave number)
O Sexton or Name of Pe i rge of Premises -3( Ire.-et &.yr%cc-h-e
W (please print)
Signature Title LP'2 relo-i4
(over)
DOH-1555 (02/20 )