Montgomery Jr, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section F #. '1 Burial - Transit Permi
Name First Middle Last Sex
John Carson Montgomery Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 18, 2015 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 7 Cedar Lane
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
.'i Medical Certifier Name Title
a.
Michael Sikirica , Dr.
Address
50 Broad Street Ste 1 Waterford, NY 12188
Death Certificate Filed District Number Register Number
4:.° City, Town or Village Moreau t��(p 2, c
0 Burial Date Cemetery or Crematory
474
December 21, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
` ; by Common Destination
-a, Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
r
t Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /�12/J/5. Registrar of Vital Statistics .41 `6et. -L
(signature)
District Number V (o 2, Place 76 4/✓) o-t° /1'L l,CC l-i-.c-c,--
I certify that the remains of the decedent identified above wre disposed of in accordance with this permit on:
`y v:.ew c.f`ta.R,` r-ev141
Date of Disposition 12/21/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot/number) (grave number)
' Name of Sexton or P rson in arge of Premises t - �t . 0-1,-ky el,e//e
�� (please pri
� nt)
IP Signature Title Cre tine'Lr
(over)
DOH-1555 (02/2004)