Galloway, Kenneth •
NEW YORK STATE DEPARTMENT OF HEALTH 7`3
Vital Records Section Burial - Transit Permit
:' Name First Middle Last Sex
Kenneth Martin Galloway Male
Date of Death Age If Veteran of U.S. Armed Forces,
• September 30, 2016 63 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 17 Fitzgerald Road
Manner of Death Natural Cause n Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12804
{ Death Certificate Filed District Number Registe Number
City, Town or Village Queensbury 5657 ( Y�,
❑Burial Date Cemetery or Crematory
III Entombment October 4,2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
f
1 Permission is hereby granted to dispose of the human r a e a e indicated.
Date Issued t b_3— I (p Registrar of Vital Statistics
(s' a ure)
District Number CS� Place It 0 (iiv\ (.l.0.e4n cc,��t,v
I certify that the remains of the decedent identified ab a were disposed of in a• orda,ce with this permit on:
WDate of Disposition (c/ 4 lib Place of Dispositio vOre r rncte!iwJ
2 (address)
W
Cl)
re (section) /' (lot number) r (grave number)
QName of Sexton or Person in Charge of Premises Lift c SiinitI-
Z (pl ase print)
W
Signature g Title Lilt 10ARA
(over)
DOH-1555(02/2004)