Loke, Gary NEW YORK STATE DEPARTMENT OF HEALTH' - H PO
Vital Records Section Burial - Transit Permit
_' Name First Middle Last Sex
Gary A Loke Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 25,2015 67 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Albany Street Address
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
ut Circumstances Investigation
W Medical Certifier Name Title
O Jeffrey D.Hubbard,MD
Address
112 State Street Albany,New York 12207
Death Certificate Filed District Number Register Number
City, Town or Village Albany
❑Burial Date Cemetery or Crematory
— March 2, 2015 Pine View Crematorium
—Entombment —Address
❑X Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
N
O Date Point of
uTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main Street,PO Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
iY
W
Ll.' Permission is hereby/ granted to dispose of the human remains describe ve as indicated.
Date Issued o2-/ If g20/3 --Registrar of Vital Statistics G/ /
(signature)
District Number Place Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z f�
Date of Disposition 3J'1 J�j Place of Disposition ,nV,,,,, Crw1dt,--%1
W (address)
N
W (section) (lot umber) (grave number)
QName of Sexton or Person in Charge of Premises anot'
Z (please print)
w �t4Signature �, Title (IW/NrR,'iTit
(over)
DOH-1555 (02/2004)