Montena, Pamela NEW YORK STATE DEPARTMENT OF HEALTH Si t -131 Vital Records Section Burial - Transit Permit
_` Name First Middle Last Sex
Pamela A. Montena Female
° Date of Death Age If Veteran of U.S. Armed Forces,
December 5,2014 56 War or Dates
''"� Place of Death Hospital,
1. p'tal, Institution or
City, Town or Village Johnsburg Street Address 224 Barney Hill Rd.
�� Manner Death
ofX Natural Cause I (Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
ILI{ Medical Certifier Name Title
John Stoutenberg
Address
':= 102 Park Street,Glens Falls,NY 12801
s; Death Certificate Filed District Number RegisterNumber
City, Town or Village Johnsburg —5.6 3
❑Burial Date Cemetery or Crematory
December 8,2014 Pine V;<w Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z —Removal and/or Held
and/or Address
1.= Hold
N
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
7 Reinterment Date Cemetery Address
.. Permit Issued to Registration Number
,' Name of Funeral Home Alexander-Baker Funeral Home 00037
-,j Address
=9, 3809 Main Street,Warrensburg,NY 12885
a Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
S. Address
7 Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued I Q)8( aN4 Registrar of Vital Statistics c, q_,
,7 (signature)
District Number 5(5� Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z Place of Disposition �v.,.,/ L1' 1 o4 —
Date of Disposition i z(��Iy p
2 (address)
Ili
U)
(section) (lot number) (grave number)
p Lilt.
Name of Sexton or Person in Charge of Premises o,Z se print) .
W
Signature -1Z-- - Title Mt-01 0 p
(over)
DOH-1555 (02/2004)