Gregory, Lloyd NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lloyd Malcolm Gregory Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 26, 2014 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Street Address 305 Guilder Hollow Rd
Manner of Death IL.] Natural Cause 0 Accident El Homicide ❑ Suicide EUndetermined ri Pending
Circumstances Investigation
Ei Medical Certifier Name Title
Thomas Kandora, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death Certificate Filed District Number - Register Number
City, Town or Village Granville 595LQ 53
0 Burial Date Cemetery or Crematory
December 29, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
AIL ❑Transportation Shipment
110 by Common Destination
0 Carrier
Disinterment Date Cemetery Address
•
IIIReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12-1 lZD(L( Registrar of Vital Statistics f`-
(signature)
District Number 5-6 Lp Place r rpu,,,� 6-can Lit. l�
`" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/29/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
tit (section) I
(lot number) (grave number)
S tilde
Name of Sexton or Perso in Charge of Premisesr., 1.—
(pease print)
Signature z Title Ctt+folf
(over)
DOH-1555 (02/2004)