Lewis, Fred NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firstrred Middle Lewis Sex Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/02/2014 78 years War or Dates
F- Place of Death Hospital, Institution or
ECity, TAW( Saratoga Springs Street Address Wesley Health Care Center
O Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
iliCircumstances Investigation
u Medical Certifier Name Title
C! Rick D. Teetz M. D.
Ad1i elsLLawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, TW6r NW Saratoga Springs 4501 165
❑Burial Date Cemetery or Crematory
04/07/2014 1 Pine View Crematory
s['Entombment Address
®Cremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2 ❑and/or
I : Address
Hold
CA
O Date Point of
Transportation Shipment
23 by Common Destination
Carrier
QDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Mi Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc. 00364
Address
402 Maple Avenue, Saratoga Springs, N Y 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cr.
In
IL
` Permission is hereby granted to dispose of the human remain e,s ib abor ' dicated
iEill Date Issued 04/04/2014 Registrar of Vital Statistics
(signature)
gii District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition gi(104 Place of Disposition go,uti,, C r1
(address)
w
Ili (section) 1 (lot number) (grave number)
ft Name of Sexton or Person Charge of Premises v+ "
Z (please print)
14 Signature /4— Title C it4fr it
(over)
DOH-1555 (02/2004)