Galka, Gary NEW YORK STATE DEPARTMENT OF HEALTH v - • Iv ill
Vital Records Section Burial - Transit Permit
• R
Name First Middle Last Sex
Gary Galka Male
Date of Death Age If Veteran of U.S. Armed Forces,
41 June 15, 2018 65 War or Dates
t. Place� ath Hospital, Institution or
Lut City, ow r Village Queensbury Street Address 35 Sugarbush Road
ill
O' Manner of Death a Natural Cause ElAccident ElHomicide ElSuicide ❑ Undetermined ❑ Pending
Circumstances Investigation
LLB Medical Certifier Name Title
Cr John Sawyer, MD,
Address
161 Carey Road Queensbury, NY 12804
Death ficate Filed District Number Regi ter Number
City ow!) Village (4u e-.- s b(.t_r y & �---) -7
❑Burial Date Cemetery or Crematory
June 18, 2018 Pine View Crematorium
❑Entombment
Address
z ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
01 Date Point of
J
At❑Transportation Shipment
XiY by Common Destination
Cr Carrier
❑ Disinterment Date Cemetery Address
I: Reinterment Date Cemetery Address
Permit Issued to Registration Number
°_ Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
Address
▪ Permission is h reby granted to dispose of the human remains described a v as indicated.
t c_Q Date Issued t laoi registrar of Vital Statistics � C.—..._I f�C� n
(signature)
District Num �') Place L �t U
b 0�.Q�Q
.i I certify that the remains of the decedent identified above were disposed of in accorda-ith this permit on:
,ut_ Date of Disposition 06/18/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
-LLE
▪0C' (section) /il (lot number) (grave number)
_a': Name of Sexton or Person in Charge of Premises ( �h,�� S�ti
Zg i(please print)
Ali; Signature Title ! k`i"iiPL2
(over)
DOH-1555 (02/2004)