Montgomery, Beverly NEW YORK STATE DEPARTMENT OF HEALTH'. • . /I ICI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Beverly Kay Montgomery F
Date of Death 1 1 /0 6/2 01 5 Age 82 If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Glens Falls Hospital, Institution or Glens Falls Hospital
ui City Town or Village Street Address
el Manner of Death L3 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
„ Circumstances Investigation
Elg Medical Certifier Name Title
CI William Cleaver MD
Address 100 Park Street, Glens Falls,NY 12801
Death Certificate Filed Glens Falls District Number r „ Register Nbs :,..-
City, Town or Village V1lJ
. ❑Burial Date 1 1 /09/201 5 Cemetery or Crematory Pine View Crematory
❑Entombment Address
®Cremation 21 Quaker Rd, Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
0 and/or Address
Hold
0 Date Point of
eL ❑Transportation Shipment
0) by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01 078
Address 136 Main St, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
1Remains are Shipped, If Other than Above
Address
Ir
LII
"" Permission is herb granted to dispose of the human re ains de ribed ab ve as indica d.
Date Issued (/ ),-' Registrar of Vital Statistics
ignature)
District Number 5100/ Place o .�=/��
certify that the remains of the decedent identified above were disposed of in accorda ce with this permit on:
ut Date of Disposition 1]/1e116 Place of Disposition ..Ra1IL C eta_
(address)
a (section) (lot number) (grave number)
lea Name of Sexton or Person in Ch ge of Premises d
t7i f S�,dt
(please pnnt)
W Signature A Title i il{leli.
(over)
DOH-1555 (02/2004)