Gallagher, John P Jr. Ill -11 log,
, .__ ,NEW YORK STATE DEPARTMENT OF HEALTH Y �� Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John P Gallagher Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/05/2022 75 Years War or Dates 1967-90
H Place of Death Hospital,Institution or
WCity,Town or Village Wilton Town Street Address 12 Craw Lane,Wilton Town,New York 12831
(] Manner of Death 0 Natural Cause Accident Homicide 0 Suicide FlUndetermined Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
0 John Pezzulo DO
Address '�^
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 50
Burial Date Cemetery,Crematory or Facility Name
09/07/2022 Pineview Crematory
Entombment Address
[Cremation Queensbury TowsNew York
DonationEt
ElRemoval Date Place Removed
and/or and/or Held
(I) Hold
Address
0
O. Date Point of
Cl)IlTransportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/06/2022 Registrar of Vital Statistics Susan Baldwin(Electronically Signed)
/signature/
District Number 4569 Place Town Of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition y I$I Z Z Place of Disposition gA(. 4----
LU (address)
W
CC (section) i (lot nu timber) (grave number)
0 Name of Sexton or Person in Cha Premises _,stivv4
Z _�^C� 4 ;hmfh) r 7)
W Signature Title ° m�f
DOH-1555(07/18)p 1 of 2
21 6214
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on uri.y1 permit
Official Funeral Directors Reg.or License#