Gallo, Alfeo YORK STATE DEPARTMENT OF HEALTH I' -1 b ~
r i Records Section Burial - Transit Permit
Name First Middle Last Sex
r
Alfeo Gallo Male
M. Date of Death Age - If Veteran of U.S. Armed Forces,
61, A• ugust 7,2013 91 War or Dates NO
P• lace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause El Accident ❑Homicide ❑Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
„t.
Suzanne Rayeski DO
Address
f100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number RegistejNumber
g City,Town or Village Glens Falls 5601 1
❑Burial Date Cemetery or Crematory
El Entombment August 12,2013 Pine View Crematory
Address
®Cremation Quaker Road, Queeensbury, NY 12804
Date Place Removed
ZZ El Removal and/or Held
and/or Address
E Hold
CO
p Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
,,, , Permit Issued to Registration Number
4 Name of Funeral Home Regan Denny Stafford Funeral Home 01443
f
r,; Address
53 Quaker Road,Queensbury,NY 12804
l Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A Permission is hereby granted to dispose of the human remains described above as indicated.
,fry
,/ Date Issued / cli(3 Registrar of Vital Statistics CAD OtAl-��
(signature)
WI r District Number 5601 Place Glens Falls
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition I IZ It3 Place of Disposition -14 1w CrivY4OrK.4..
2 (address)
W
CL (section) A lot number) (grave number)
4.
p Name of Sexton or Person 'n Charge of Pr mises .$t Sr
Z cf(please print)
uJ Si nature `
9 G Title Carilawirsst
(over)
DOH-1555(02/2004)