Loucks, Edward John # 2 s)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edward John Loucks Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/18/2022 91 Years War or Dates 1950-1953
i_ Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 39 Longview Drive Apt.143,Queensbury Town,New York 12804
ail
p• Manner of Death El Natural Cause EAcci El HomicideSuicide ❑Undetermined Pending
✓ Circumstances Investigation
Q Medical Certifier Name Title
Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town of Queensbury District Number Register Number
,Town or Village Cie 5657 55
Burial Date Cemetery,Crematory or Facility Name
03/21/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
Z• Removal Date Place Removed
p and/or and/or Held
N Hold Address
0
a Date - Point of
f/)DTransportation
b by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
DReinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/21/2022 Registrar of Vital Statistics Calvin,7fd gardiBarler(EQctronrcaQySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
It—
Z Date of Disposition _ 3113I2L Place of Disposition V__ Ate,.... ,
2 (address)
IILI
CO
Q (section) d(lot number) (grave number)
gName of Sexton or Person in Chage of Premises 4"r^1 '�tr
dr (plea+print) �^W ve
Signature Title ` mb
DOH 15551o7/18)p 1 of 2
,.< .� 5 2
a
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#