Galick, Edward ,1EW YORK STATE DEPARTMENT OF HEALTH #!L2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward John Galick Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 17, 2014 92 War or Dates
Place of Death Hospital, Institution or
; City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
- Medical Certifier Name Title
Thomas Kandora, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
u Death Certificate Filed District Nun210s Register' Number
City, Town or Village Fort Edward 5.1 b
❑Burial Date Cemetery or Crematory
February 19, 2014 Pine View Crematory
4-4
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
P• ermit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
' Address
123 Main St., Argyle NY 12809
N• ame of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is ereby granted to dispose of the human r ' s describ d abo e as indicated.
till
Date Issued ( ( Registrar of Vital Statistics
(signatu
District Number n1.6_5 Place f( th\ Q� FOL &bQAG
: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/19/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) i (lot number) (grave number)
N• ame of Sexton or Person . Charge of Premises Ile+ -f Stnr,¢i
(please print)
Signature Title C 4/11-r it
-,..1,,-'-':- 71-- ....L--
(over)
DOH-1555 (02/2004)