Galick, Ann Margaret NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ann Margaret Galick - Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/26/2023 96 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death n Natural Cause nAccident Homicide Suicide Undetermined ❑Pending
W I Circumstances Investigation
U
W Medical Certifier Name Title
p Philip Gara MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 12
▪Burial Date Cemetery,Crematory or Facility Name
01/30/2023 Pine View Crematory
Entombment Address
▪Cremation Queensbury Town,New York
Donation
Z Removal❑ Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
El
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
E Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/30/2023 Registrar of Vital Statistics .limeeL'lakoney(ElectronicalySOned)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
yr--�
Z
Date of Disposition I 1.31 13,3 Place of Disposition t
2 (address)
O (section) /A ((lotrumber) (grave number)
Name of Sexton or Person in Chriesp se print)
Ui ( r W Signature , Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' delivered on , 20 `
Pine View Cemetery Representiflg the funeral home named on burial permit
Official Funeral Directors Reg.or License#