Loffler, Ross Adam r # I2 ,
NEW YORK STATE DEPARTMENT OF HEALTH .,Trial - Transit Permit
Bureau of Vital Records
Name First Middle Sex
Ross Adam Loffler Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/28/2020 79 Years War or Dates 1961-1964
i_ Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Marcille Labban MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 535
Burial Date Cemetery,Crematory or Facility Name
11/30/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0 El Removal Date Place Removed
and/or and/or Held
N Hold Address
O
G. Date Point of
Cl) Li Transportation
O by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
CC
LLi
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/30/2020 Registrar of Vital Statistics Ro6ertf7n�rew Curtis( ctronicall:y Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 12 �I � ?Q Place of Disposition
(address)
LL1
(section) lotember) (grave number)
g Name of Sexton or Person in Char of Premises r. j� ^isir
(pleas print)
W Signature ��� Title COitet
^al
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 4 2 4 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#