Montgomery, Beatrice F NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Beatrice:...................:.......:.................F.....:• _:.....Montgomery....: .:.:...._ .............: female
.: :. ......
................................
ate of Death Age If Veteran of U.S.Armed Forces,
January 19 1992 95 ...:....WarorDates...............::: no::..............:: :: ..............
�..� .:.... : . ..::...: .....:......:................x.......:......:::: .
Place of Death Hospital, Institution or
W City,Town or Village Tn of Queensbury. Street Address Hallmark...Nursln.....Q.e.ntre-.::::::::..:.
G Manner of Death � Natural Cause Accident Homicide Suicide Undetermined ending
W Circumstances Investigation
Wi
Medical Certifier Name Title
A. Garner _ ..................MD.: :....:.........
....... ............:..::.. .. ..................................:.............................. _ ........ ......:
Address
88...Broad Street, Glens.. Falls:,.:.New:.York.:.128:91 .. ....:
Death Certificate Filed District Number Register Number
City Town or Village Tn of Queensbury 'St v S 7
Date Cemetery or Crematory
..: .. matory.....:...:...:.:.......... : :.
❑Burial January.: :.:21' 1992 Pine View .Cre
.....:..: ........ .
®Cremation Address
.......
Queensbury:,: New_..York....12..804.......
Z Date Place Removed
O, Removal and/or Held
F-i and/or Hold ... ......... ......... ...... ... ...... :: ... ........
..............
Address
O....................................... ........ . .......... ........
a Date Point of
to ❑Transportation by Shipment
pl Common Carrier ........ ... :::......:................... _ .. . ...::-:. ...........................................................
Destination
..... ..-_ ry
❑ Disinterment Date Cemete Address
::. ... ..... .
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Regan and Dennyuneral Service Inc,.,,.,.. .. 01602
9 . Y ... .......::.,
Address
26 Quaker Road, Queensbury,_New York 12804,_ .. ....... ..............
... . :::. ................::.......:............
-' Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, If Other than Above
..........................:.:... ............ -...... ........... ................_ - ......... .. .......... ...........:
Address
Permission is hereby granted to dispose of the human r mains describ ii'above as indicated.
> Date Issued - Registrar of Vital Statistics
(signat re)
District Number Place
I certify that the remains of the decedent identified above were disposed of in laccordance with this permit on:
W Date of Disposition /0-f- Place of Disposition //i/��
(address)
w
(section) (lot number (grave number)
pi Name of Sexton o Person in Charge of Premises r�
Z (please print)
W Signature Title e��/0/}T/'rXJ�i°
DOH-1555 (10/89) p. 1 of 2 VS-61