Galusha, John r. . to
- St 2
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
Y.4' Name First Middle Last Sex
John Matthew Galusha Male
Date of Death Age If Veteran of-W.S.'Armed Forces,
July 02,2017 49 War or Dates
tom-. Place of Death Hospital, Institution or
ZCity, Town or Village Queensbury Street Address 15 Belle Ave,Queensbury,NY
ip Manner of Death J Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
w Medical Certifier Name Title
Pi Michael Sikirica MD
Address
New Scotland Ave,Albany,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury tx 5`k gs
M❑Burial Date Cemetery or Crematory
July 05,2017 Pine View Crematorium
El Entombment Address
®Cremation Quaker Road,Queensbury,NY
Date Place Removed
Z❑Removal and/or Held
and/or Address
Hold
a Date Point of
N❑Transportation Shipment
• by Common Destination
• Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Carleton Funeral Home,Inc. 00281
_ Address
68 Main St.,Hudson Falls,NY 12839
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
Address
t
0.• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1-5-,10 I i Registrar of Vital Statistics '�COX -mac Q A ___
(signature)
District Number SVS 7 Place 00 teA S.hv!
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 7-1"I"7 Place of Disposition fntU� 14or1.-.
a (address)
CO
Ce (section) (lot nu ber)- (grave number)
QName of Sexton or Person in Charge of Premises ar,)1tit.,^ 4,14w1tt-
Z (please print)
Lli
— Signature a Title (MOM(ILli .-
(over)
DOH-1555 (02/2004)