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Rock, Lloyd VIA NEW YORK STATE DEPARWENTkJF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Lloyd David Rock Male Date of Death Age If Veteran of U.S. Armed Forces, February 13, 2017 72 War or Dates Place of Death Hospital, Institution or w City, Town or Village Glens Falls Street Address Glens Falls Hospital WManner of Death Natural Cause ❑ Accident D Homicide ❑ Suicide ❑ Undetermined ri 1-1 Pending CircumstancesInvestigation W Medical Certifier Name Title Michael Miles, Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number 60 City, Town or Village Glens Falls 6 ❑Burial Date Cemetery or Crematory February 15, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held { and/or Address F. Hold Date Point of Transportation Shipment Ca by Common Destination p Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 'Z l ( 5 I (-7 Registrar of Vital Statistics Uk..)c,,,L- 1 (signatur District Number 5 Ca ( Place 6 Ci To.s V' 5 /t 9 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 02/15/2017 Place of Disposition Quaker Road Queensbury,NY 12804 ille-„ (--/ k? (address) W (section) (lot number) (grave number) 2 Name of Sexton or harge of Premises w/let✓1 t 47_i (please print) W Signature Title L-t'-y1i T c? 710 7- (over) DOH-1555 (02/2004)