Lewis, John NEW YORK STATE DEPARTMENT OF HEALTH 1 ?
Vital Records Section Burial - Transit Permit
1, ,-`1 Name First Middle Last Sex
John Michael Lewis Male
Date of Death Age If Veteran of U.S. Armed Forces,
Vv,v 12/09/2018 70 War or Dates
Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death❑Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending
Circumstances Investigation
, '`'' /7/i
Medical Certifier am
a dress
T ` / ��� sT R
AP A4,, a,,,,,. //7/4,37_
District Number I Register Number
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,, Death Certif+sate Filed C � /// F'
City,Town or Village /J,s l/f `3 r�69/ I S('J
❑Burial Date CPmptpry or %a,i
Cre atory
"' ❑Entombment Address 12/14/2018
,i/� ms C�L-ees,-r� /v
44®Cremation 02j!- r/1/17 .��%/�' , )`/<
fl:
Date
� Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. I 00141
1 1 Address
," 9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
tRemains are Shipped, If Other than Above
Address
Permission is herebygranted to dispose of the human remains described above as incicated.
F ' Date Issued l-2.)i'24 kc' Registrar of Vital Statistics WC),A)Yy.% \.l..-),(-��
(signs re)
tiff „F'
District Number S6O ( Place G VQ,\.\. 1v 'Li;
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (Z'IttI$ Place of Disposition gill..., , 0-,
(address)
(section) , (lot numb ) (grave number)
Name of Sexton or Person in Charge of Premises t �'"i L e'""'W�
(phase print)
Sig nature6 Title fF' + a-
(over)
DOH-1555(02/2004)