Galligher, John e
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First his Last Sexnn
�—o4A
Date of Oeath — I — �� Age If Veteran of U.S. Armed Forces,
War or Dates n; Q
Place of Death Hospital, Institution or 1
City, Town or Village t'NS �� Street Address 5 F(�LLS OS�i �—
Manner of Death r7ONatural Cause Accident Homicide Suicide EJ Undetermined Ej Pending
Circumstances Investigation
Medical Certifier Name Title
`fit\ �O C
Address
C� G-LE 's AL s �f1 1 a
Death Certificate Filed Di trict Number RegisfW Number
City, Town or Village Gy�r✓'�js L S
Date , Z4weeter�y or Crematory
❑Burial —a3—qJ NEvl t�� zl
Address
Yd Cremation (� �E2 CA L O 1
Date PI ce Removed
8 FI Removal I and/or Held
and/or Address
Hold
Q Date Point of
NQ Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home �Ck�C C D 1 S
Address
' C) o C L ' LR.
Name of Funeral Firm Making Disposition or to Whoph
Remains are Shipped, If Other than Above
Address
Q.
Permission is hereby granted to dispose of the human remains described above as ' dicated.
Date Issued Registrar of Vital Statistics
(signature)
/ \/
District Number601 Place o /l S, /U/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition` Place of Disposition %�YiF^
+� (address)
N
>l (section) (lot numbbp ) / (grave number)
Name of Sexton r Person n Charge of Premises
g (please print)
W Signature Title OK
DOH-1555 (10/89) p. 1 of 2 VS-61