Gallagher, Robert e -4 4-3' 1 W 1�NEW STATE DEPARTMENT OF HEAt,fiH Burial � Transit Permit
Vital Records Section
Name Fir Middle Last , 1 Sex �n
{,P1+ LL7- Galls( ' r v
Date of Death I Age i if Veteran of U.S.Armed For , -,
lb LL1-1 17 I 92? War or Dates )(1O crow) good 1'4 110 *13
1.- Place of Death I Hospital, Institution or
I City:Tow r Village Oup l-N.3�, s Street Address V i p-ij-tr-,r�
lei Mann each Natural Cause E.A ident O Homicide O Suicide Undetermined O Pending
Lt1 - Circumstances Investigation
w Medical Certifier Name Title i� ,
CI t 11 t CCM Pair i'k-►� �' LI S 1 C.-C. '1
Address
lob ? o c'. 5-�-, Gi lj (' 1.)\-/ 1-2,k0
Deat ificate Filed ne Number Register Number
City Town r Village C16P�1,o 7111� t ` 1 \ c
OBurial Date C Cemetery or emato
OEntombment Address i
Cremation 0 U61 - -{ 0 oe.e ni hu N---i 1- cs'
Date Place Removed
O Removal and/or Held
and/or Hold Address
0 —I Date Point of
Transportation Shipment
ez by Common Destination
Carrier
Disinterment Date r -m'':ery Address
Renterment Date i Cemetery Address
( - Permit Issued to I Registration umrlber
Name of Funeral Home pi\ Funeral Home U(jj3V
Address
ij ' w . WPC
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
Address ---
so
tav
Permission is hereby granted to dispose of the human r mains describe' above as indicated.
Date Issued c 1 Registrar of Vital Statistics QC 8-r- ._
(signature)
District Numbecc-•) Place ()L-rC _ _ . !Z. ___.,.1
I certify that the remains of the decedent identified above were disposed of in a cord-nee with this permit on:
E 1 Date of Disposition it)11 jig Place of Disposition r;,,o¢,.r.,
(address)
WI
I (section) (lot n ber) (grave number)
Name of Sexton or Person in Charge of Premises b^r jt r 3 t AIO..
1 ILI /, (please prht)
i Signature (,�1 �c'� Title - �kP►i�(tX�
(over)
DOH-1555 (02/2004)