Andrews, Levi NEW YORK STATE DEPARTMENT OF HEALTH i l 10
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
Levi S. Andrews Male
cli:.' Date of Death Age If Veteran of U.S. Armed Forces,
February 14, 2014 49 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address
C` Manner of Death Natural Cause Accident Homicide Q Suicide Undetermined Pending
Circumstances Investigation
ICJ; Medical Certifier Name Title
C Gary Scidmore,
Address
1340 State Route 9 Lake George, NY 12845
D-- -te Filed ,'\, Dis ct Number Re Ater r Number
V ity, Town or illage (-�C . (9c
❑ :, '- Date Cemetery or Crematory
Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
E Hold Pine View Cemetery
_
CO Date Point of
j ❑Transportation Shipment
) by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
3 Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
7.5 ' 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
Address
lir
Permission is hereby granted to dispose of the human r m ns descr' a ve asp indicated.
Date Issuecc\‘,g \_p Registrar of Vital Statistics G� u f - —--
` `J—, (signature)
District Number cl_D S-1 Place I lam d c ('_
I certify that the remains of the decedent identified above were disposed of in accLanc ith this permit on:
11--
WDate of Disposition )/J0)l'4 Place of Disposition Queensbury,NY 12804 �;it.,, (r,,,�,�t,,...
x`' (address)
Ui
01
:, (section) (lot number) (grave number)
04
cr Name of Sexton or Person in Ch ge of Premi es da. r Sent*
(please pent)
Ui Signature oL Title C i1 (
g
(over)
DOH-1555 (02/2004)