Galloway, Arthur NEW YORK STATE DEPARTMENT OF HEALTH 3 Burial - Transit lPermit
Vital Records Section
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l Name First Middle Last Sex
Arthur V. Galloway Male
Date of Death Age If Veteran of U.S.Armed Forces,
1, April 5, 2013 95 War or Dates World War II
Z Place of Death Hospital, Institution or
W City,Town, or Village Granville Street Address The Orchard Nursing Centre, Inc.
0 Manner of Death ®Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Carl Beckler MD
0 Address
278 VT Route 149 West Pawlet Vermont 05775
Death Certificate Filed District Number Register Number Ii,,
City,Town or Village Granville J' 6- 6 z
❑Burial Date 04/10/2013 Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
Z 0 Cremation Town of Queensbury
Date Place Removed
0 ❑Removal and/or Held
and/or Address
F Hold
0 Date Point of
0 ❑Transportation Shipment
O. by Common Destination
Carrier
Date Cemetery Address
5 ❑Disinterment
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
a
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l:g'j3 Registrar of Vital Statistics L .,,tL , n
(signaturtur )
District Number S7S(0 Place Granville,New Y k
1- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition L4 In-i3 Place of Disposition t dd ss) �r ty.4-t IVr'n
w
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0 (section) (lot 9pmber, (! (grave number)
O Name of Sexton or Person in Charge of Premises f�'7i�)'�t�`;r.- wuul'�
Wz / ! (please priht)
Signature ( 1... Title ie iA Oi(
(over)
DOH-1555 (02/2004)