Galusha, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital RecordsSection Burial - Transit Permit
,. Name First Middle Last Sex
George Raymond Galusha Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 24, 2017 85 War or Dates
Plac eath Hospital, Institution or
City ow or Village Queensbury Street Address 15 Belle Avenue
W, Mann r of Death Natural Cause El Accident I:: Homicide ❑ Suicide ❑ Undetermined El❑ Pending
0 Circumstances Investigation
WW, Medical Certifier Name Title
Dr. Donald Merrihew,
Address
Convenient Medical Care Queensbury, NY 12804
Deat, ificate Filed Nw pe� e Number
City, 1 • i or Village ,wee ; �`
\36iA.'7 rCtPS
i
®Burial Date ( Cemetery or Crematory
March 29, 2017 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
� Removal and/or Held
I and/or Address
Hold Pine View Cemetery
0: Date Point of
Al 0 Transportation Shipment
by Common Destination
A
Carrier
_; Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
7-
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
, Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
III
Permission is hereb granted to dispose of the human tmains desc 'bed a ov as indicated.
1. Date Issued3b--) 1Registrar of Vital Statistics C-,,._, �
z - / (signature)ii
District Number Sc9.s Place 1 d �--r, C) -i- C-Q1-A—Q-J2-Cli-
,,_„,
;Z' I certify that the remains of the decedent identified above were disposed of in ac •rdance wit this permit on:
g., Date of Disposition 03/29/2017 Place of Disposition Quaker Rd. Queensbury,N' =e-
2 (address)
iLli
In—
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (02/2004)