Loomis, Herbert NEW YORK STATE DEPARTMENT OF HEALTH -� fi
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Herbert A. 4) Loomis Male
, Date of Death Age if Veteran of U.S. Armed Forces,
6: September 5,2018 79 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Chester Street Address 47 Bird Pond Rd.
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
wMedical Certifier Name Title
Dr.John Rugge,MD
Address
u HIHIN,North Creek,NY 12853
Death Certificate Filed District Number Register Number
City, Town or Village Chester 5652 1 4
❑Burial Date Cemetery or Crematory
1
Entombment September 11,2018 Pine View Crematory
Address
❑X Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date 1 Cemetery Address
Reinterment Date Cemetery Address
z' Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom -
44, Remains are Shipped, If Other than Above
Address
°tea
.: Permission is hereby granted to dispose of the human remai e cribed above as indicated.
Date Issued a(—6-a Registrar of Vital Statistics
ature)
District Number 5652 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 1 lit Ili Place of Disposition UN.- i o,-
2 (address)
Cl)UJ
Q0 (section) (lot nu p�er) (' (grave number)
Name of Sexton or Person in Charge of Premises ( stt yr StA*itr
Z (please print
W Signature i1 el.tG' Title ilikin{MI,
(over)
DOH-1555 (02/2004)