Montgomery, Dawn C. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dawn C.Montgomery Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/24/2021 58 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address 380 Madison Avenue,Albany,New York 12210
`p Manner of Death Natural Cause ElAccident ❑Homicide Suicide Undetermined ElPending
Circumstances Investigation
W Medical Certifier Name Title
Antonio Sturges Coroner
Address
175 Green Street,Albany,New York 12202
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 0621
Burial Date Cemetery,Crematory or Facility Name
02/27/2021 Pine View Crematory
Entombment Address
EICremation Queensbury Town,New York
Donation
8 ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
CL Date Point of
t/1 1-1
Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/26/2021 Registrar of Vital Statistics Danie(T S Gillespie(ECectronicautySigned)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 03-a 7- 41/ Place of Disposition ;
(add
(section) (lot number (grave number)
°C
8 i?A��rn.�d r.
Name of Sexton or Person in Charge f Premis
Z —� (please print)
W Signature f& 7-1j. Title a�I rb i�T
DOH-1555(07/18)p 1 of 2 I
Public Health Law Sec. 4145(2b) ) 14 5 9 3
Receipt
Human remains of delivered on , 20
I
r
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#