Galusha, Joseph NEW YORK STATE DEPARTMENT OF HEALTH tz
Vital Records Section ,� Burial - Transit Permit
Name First Middle Last Sex
Joseph L. Galusha Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 28,2011 66 War or Dates
1,,. Place of Death Hospital, Institutiorl)tliirondack Tri-County Health Care
Z City, Town or Village Johnsburg Street Address Center
ci Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
#w_ Medical Certifier Name Title
01 Thomas Warrington
Address
HHHN,Johnsburg,NY 12843
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 6
❑Burial Date Cemetery or Crematory
January 28,2011 Pine View Crematory
El Entombment Address
®Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
ca
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
f- Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
E, Address
K
W
O. Permission is hereby granted to dispose of the human remain
describedj�� abov indicated.
/2 Registrar of Vital Statistics (�C�...41C.i-' e � �
Date Issued / J 11 g
f (signature)
District Number 5655 Place Johnsburg
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LU Date of Disposition 7IktO 31 k it Place of Disposition lAt Olc,d4 c r IL.,
(address)
W
CO
CL (section) (lot number)e-- (grave number)
pName of Sexton or Person in Charge o remises t r,.jtgp�,r^ Jr K-itt
Z /AL
(please print)
W Signature Title __i_
(over)
DOH-1555(02/2004)