Galusha, Geneva t (0" u
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Geneva Lucille Galusha Female
,, Date of Death Age If Veteran of U.S. Armed Forces,
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May 27, 2017 82 War or Dates —
Place of Death Hospital, Institution or
U` City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
titManner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
(1 Circumstances Investigation
W Medical Certifier Name Title
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Philip J Gara Jr. MD,
Address
327 Broadway Fort Edward, NY 12828
Death Certificate Filed District Numb 55 Register umber
City, Town or Village �p
❑Burial Date Cemetery or Crematory
May 30, 2017 Pine View Crematorium
❑Entombment Address
id®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold Pine View Crematorium
Date Point of
p�, ❑Transportation Shipment
by Common Destination
i Carrier
❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
i `^`j Permit Issued to Registration Number
AN,' Name of Funeral Home Carleton Funeral Home, Inc. 00281
N Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
IA Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
F Address
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Permission is hereby granted to dispose of the hunln ins slescri e a ove ndicated.
Date Issued 5-3D- (i Registrar of Vital Statistic
G
(signature)
District Number 5-7 5 5 Place /(sum06l �ciwcAc /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:'` Date of Disposition 05/30/2017 Place of Disposition Quaker Road Queensbury,NY 12804 ?f)1QA..)i /Gi
' (address)
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l : (section) (lot number) (grave number)
ri, Name of Sexton or P n i Char a of Premises 3 k ire-si 6)4,444 azAe
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',�+' (please prim)
W. Signature Title eiria-en-t-
(over)
DOH-1555 (02/2004)