Loftus, Gerald NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerald J. Loftus Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 25,2014 72 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls — Street Address Glens Falls Hospital
is Manner of Death T Natural Cause _Accident ❑Homicide n Suicide n Undetermined n Pending
AlkCircumstances Investigation
Medical Certifier Name Title
Dean Reali,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 S9 5-
0 Burial Date Cemetery or Crematory
December 29,2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
Cl)
O Date Point of
Nn Transportation Shipment
aby Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A.
Permission is hereby granted to dispose of the human remains described above as indicated.di-
Date Issued /2/2 61/Li Registrar of Vital Statistics (' �� kU
(sign ure)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition I Lf.3alh Place of Disposition 17.4 tit....
W (address)
co
cc (section) (lot numbper) (grave number)
Q Name of Sexton or Person in Charge of Premises di A9L Jtdoll
Z (please print)
W
Signature Title 1ZE$+ (
(over)
DOH-1555(02/2004)