Montello, Nicholas Anthony i
— 4 I )
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nicholas Anthony Montello Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/01/2022 19 Years War or Dates -
E. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause IllAccident Homicide nSuicide nUndetermined Pending
ift Circumstances Investigation
W Medical Certifier Name Title
0 Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 135
Burial Date Cemetery,Crematory or Facility Name
® 03/03/2022 Pine View Crematory
Entombment Address
JCremation Queensbury Town,New York
Donation
oz❑Removal Date Place Removed
and/or and/or Held
ip,CO
Address
0
Date Point of
tf) Transportation Shipment
by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 —
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
, Remains are Shipped,If Other than Above
IAddress
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/03/2022 Registrar of Vital Statistics MeganNoln(E(ectronicaaySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 4na
I— .Z Date of Disposition Alva ilt Place of Disposition — -
two
W (address)
W
to (section) /� (lot number) (grave number)
cie
it
Name of Sexton or Person in Charge of Premises t 1 01\sg 6-- 1
ease print/
liZtl' g Title £�?�an+ r
Signature
DOH-1555(07/18)p 1 of 2
j1 5 Y. Q
Public Health Law Sec. 4145(2b)
Receipt
Human remains of -' delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#