Monthony, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
r : Name First Middle Last Sex
: °§? David F. Monthony Male
Date of Death Age If Veteran of U.S. Armed Forces,
n March 1,2014 65 War or Dates 1968- 1970
Place of Death Hospital, Institution or
a City, Town or Village Glens Falls Street Address Glens Falls Hospital
k Manner of Death n Natural Cause [ I Accident Homicide 1 Suicide Undetermined Pending
, Circumstances Investigation
ii Medical Certifier Name Title
Daniel Way
T:
Address
ta
�$���,North Creek,NY 12853
b «, Death Certificate Filed District Number Register Number
µ City, Town or Village Glens Falls 5601 q (z
❑Burial Date Cemetery or Crematory
March 5,2014 Pine View Crematory
0 EntombmentAddress
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
1' Hold
N
0 Date Point of
O.
n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
1 }Reinterment
Date Cemetery Address
Permit Issued to Registration Number
farm# Name of Funeral Home Alexander-Baker Funeral Home 00037
n Address
- "; 3809 Main Street,Warrensburg,NY 12885
E oar
=a 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.
#:.::
, s;f Date Issued 3/ 3 1 (L( Registrar of Vital Statistics (_") Ce ti,,--Q �n)
$n:,„' ( (signatur
° x.' District Number 5601 Place Glens Falls
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3 h IN Place of Disposition �C/_ v..j a-r.
g (address)
W
CZ
(section) (lot n(�`ber) (grave number)
pName of Sexton or Person in Charge of Premises «j t<., 3141,4—
Z (please print)
W 4.1-
Signature LTitle Crave r 't.
(over)
DOH-1555 (02/2004)