Gallagher, James NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
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K Name First Middle Last Sex
James M. Gallacher Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 9,2015 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 95 13th Lake Road
xt.0 Manner of Death
�' I X+Natural Cause L [Accident Homicide Suicide Undetermined -Pending
W, Circumstances Investigation
u Medical Certifier Name Title
0 William Orluk
Address
'. Chester Health Center,Chestertown,NY 12817
Death Certificate Filed District Number Register Number
City, Town or Village 5655 1
❑Burial Date Cemetery or Crematory
October 13,2015 Pine View Crematory
ri Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z 1 I Removal and/or Held
and/or Address
F' Hold
N
O Date Point of
co 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 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
FR' Remains are Shipped, If Other than Above
Address
OC
tit
Permission is hereby granted to dispose of the huma - ains describe above a i dicated.
, Date Issued lb - 15 Registrar of Vital Statistics ZD cI
(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:
W Date of Disposition )Ohjy J)s Place of Disposition egu IL Cvv(on .-
W (address)
CO
Ce
(section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises rArt,t )1004
(please print)
W .„.4..
Signature It. Title r1.fti}Q��
(over)
DOH-1555 (02/2004)