Galusha, Elizabeth NI
.
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
-.- Name First Middle Last Sex
Elizabeth J. Galusha Female
Date of Death Age If Veteran of U.S. Armed Forces,
,. March 12,2011 68 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address Whitewater Manor
ILI
0 Manner of Death X Natural Cause Accident [ 1 Homicide Suicide Undetermined Pending
LI Circumstances Investigation
W Medical Certifier Name Title
:g Daniel Way
Address
_._ HHFIN,North Creek,NY 12853
Death Certificate Filed District Number Register Number
{ City, Town or Village Johnsburg 5655 ) q
❑Burial Date Cemetery or Crematory
March 14,2011 Pine View Crematory
0 Entombment Address
®Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
0 Date Point of
N Transportation Shipment
p by Common Destination
_ Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;, 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
N Address
IA.
Permission is hereby granted to dispose of the human rem ins described abo :s indicated.
Date Issued ,311 J 1 aO (1 Registrar of Vital Statistics ,�C�71.4s-.- 6 •a. .�-_
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3-(1-‘1 Place of Disposition giutitew tdrive...
W (address)
Cl)
(section) (lot num)er) (grave number)
pName of Sexton or Person in Charg of Premises r, j o"reft-
Z (please print)
W Signature a*L, Title Ch ►>n ►.,'("Or.,
(over)
DOH-1555 (02/2004)