Lloyd, Thomas r . 'It 4 6q(
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas M. Lloyd Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 9,2017 87 War or Dates Korean
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
�� X Natural Cause � �Accident � �Homicide Suicide
Circumstances Investigation
W; Medical Certifier Name Title
as Dr.North
Address
HiIIIN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 Li g'I.j
❑Burial Date Cemetery or Crematory
Entombment September 13,2017 Pine View Crematory 11 Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
N Hold
Cl)
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
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
I-. Remains are Shipped, If Other than Above
X Address
Cr
US
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 I i 'f 20 t 7 Registrar of Vital Statistics L..)c.,� y,Q,
(signet e)
District Number 560 r Place G (ASS t--o,\ V 5 4V V -.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition / oil n Place of Disposition lino £ -e.4o".r
W (address)
CO
pIZ (section) (lot number}- (grave number)
Name of Sexton or Person in Charge of Premises _ ) ,AA 4
Z (plese print)
W Signature �l -/4r" Title C fi),tl'7Jr2
(over)
DOH-1555 (02/2004)