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Lewis, Joseph NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Joseph Richard Lewis Male Date of Death Age If Veteran of U.S. Armed Forces, August 21, 2016 69 War or Dates F Place of Death Hospital, Institution or WCity, Town or Village Fort Edward Street Address 536 Lower Allen St. Ci Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending W Circumstances Investigation U W Medical Certifier Name Title in Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 Death Certificate Filed District NumtV- 65 Regist�e�'I umber City, Town or Village I `fir ❑Burial Date Cemetery or Crematory August 24, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z r-i Removal and/or Held 0and/or Address H' Hold CT) Date Point of a ❑Transportation Shipment (l) by Common Destination 3 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment '' Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address X W W Permission is here y granted to dispose of the huma ins scrib d b e icated. Date Issued 16, Registrar of Vital Statistic �-Q / 10 r itej �-� , (signature) District Numbe5 5 Place !Gli} . 66 1 art / I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Pit 'e V, Grl v w Date of Disposition 08/24/2016 Place of Disposition Quaker Road Queensbury,NY 1 804 W (address) f!}''' Ce (section) } 1 /(I t number) (grave number) pName of Sexton or er on in Charge of Premises NJ I.-1 i�-✓i (94.4 Z4-1,4 z (please print) W''' Signature Title Ere— '' (over) DOH-1555 (02/2004)