Davis, Lloyd v)` 1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Lloyd -_ Reuben Davis j Male __
Date of Death Age If Veteran of U.S. Armed Forces,
___M 'ch-13, 1999 87 War or Dates WW II
Place of Death Hospital, Institution or
City, T4OMNIONtEna Glens Falls Street Address Eden Park NursingNUrsing_Rome
Manner of Death Undetermined Pending
]Natural Causes❑Accident ❑ Homicide El Suicide ❑ Circumstances Investigation
Medical Certifier Name Title
Robert L. Evans DO
Address
3 Irongate_Center, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TgOtittifg@cx Glens Falls 5601 1. 3 Z
Date Cemetery or Crematory
ri Burial March 16, 1999 Pine View Cemetery
❑ Cremation Address
Tn of Queensbury, NY
Date Place Removed
Removal and/or held
and/or hold Address
Date Point of
CTransportation by Shipment
Common Carrier
Destination
Date Cemetery Address
UDisinterment
Date Cemetery Address
CReinterment
Permit issued to I Registration Number
Name of Funeral Firm Carleton Funeral Home Inc. 00313
Address — ---
P.O. Box 67, 68 Main St. , Hudson Falls, N.Y. 12839
Name of Funeral Firm Making Disposition or to Whom
•Ren.ains are Shipped, If Other than Above
` Address
Permission is hereby granted to dispose of the human remains described above s i dic ted.
Date Issued3>>5/99 Registrar of Vital Statistics —(Signature)
District Number 5601 Place Glens Falls, NY 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition_ 4[211499Place of Disposition Pine View Cemetery , Queensbury N_Y_--_
(address)
Huron 6-E
(Section) (Lot Number) (Grave Number)
Name of Sexton or Person in Charge of Premises_ Rodney G . Mosher
(Please Print)
Signature_ y Title _ Superintendent
DOH-1555 (10/89) p. 1 of 2 VS-61