Loomis, Daivd NEW YORK STATE DEPARTMENT OF HEALTH It I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David C. Loomis Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 3,2014 48 War or Dates
. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
tp Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
0
W Medical Certifier Name Title
O John Stoutenberg
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed I District Number Register Number
City, Town or Village Glens Falls 1 5601 V4'
❑Burial Date Cemetery or Crematory
❑Entombment January 8,2014 Pine View Crematory
Address
El Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 and/or Address
H Hold
to
0 j Date Point of
N Transportation ; Shipment
p by Common I Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home I 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
2 Address
W
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I i 0-6 f1 l Registrar of Vital Statistics L.A.)NA,\
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 1 /1 114 Place of Disposition ZituttM! actor r�
W (address)
(section) lot numb (grave number)
p Name of Sexton or Person in Charge of Premises t-si pot
l ham,*
Z r(please print)
W
Signature Title reii4tretf-
(over)
DOH-1555 (02/2004)