Monty II, Glen NEW YORK STATE DEPARTMENT OF HEALTH t- Burial - Transit Permit Vital Records Section
Name First Middle Last Sex
Glen T Monty II Male
Date of Death Age If Veteran of U.S.Armed Forces, NO
F July 21, 2011 t4 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address 8 Elizabeth Street
0 Manner of Death ®Natural Cause 0 Accident 0 Homicide D Suicide 0 Undetermined Pending
W Circumstances Investigation
() Medical Certifier Name Title
W Dr. Glen Chapman, M.D. Dr.
Q Address
P.O. Box 29 Ticonderoga New York 12883
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall O-7� `
❑Burial Date Cemetery or Crematory
July 25, 2011 Pineview Crematorium
❑Entombment Address
®Cremation Queensbury Queensbury, NY 12804
Date Place Removed
0 El Removal and/or Held
iim and/or Address
h' Hold
0 Date Point of
0 Transportation Shipment
d by Common Destination
Carrier
. Date Cemetery Address
0 0 Disinterment
Ell Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
H
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remains described abov as indicated.
Date Issued -- 02- g/7 Registrar of Vital Statistics c -
(signa e)
District Number 5"76 67 Place Whitehall,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 07/25/2011 Place of Disposition Pineview Crematorium
W (address)
N
Cr (section) L _(}t umber (grave number)
ZName of Sexton or Person in Charge f Premises r i s o- wy�
W14L
(pl ase print)
Signature t/ Title C2 14;dvC
(over)
DOH-1555 (02/2004)