Lewis, Robert P it 43
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert P. Lewis Male
Date of Death Age If Veteran of U.S.Armed Forces,
8/1/2021 94 War or Dates -
Place of Death Hospital,Institution or
WCity,Town or Village Bolton Street Address 224 S.Trout Lake Rd.,Diamond Point
p Manner of Death 0 Natural Cause 0 Accident El Homicide El Suicide ❑Undetermined El Pending
tL Circumstances Investigation
0
W Medical Certifier Name Title
a Peter Gray MD
Address
3 Iron Gate,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village T/O Bolton 5650 09
Burial Date Cemetery,Crematory or Facility Name
Entombment 8/4/2021 Pine View Crematory
Address
EjCremation
El Donation 21 Quaker Rd., Queensbury,NY 12804
z Removal Date Place Removed
and/or and/or Held
f- Hold Address
U)
0
a• Date Point of
U) Li Transportation
CI by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
11 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 0037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described abov as indicated.
Date Issued 05 0-1 2024 Registrar of Vital Statistics
` (signature)
District Number 5650 Place T/O Bolton,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition //4 1 74 Place of Disposition „,..LL .--
2 (address)
W
NCC (section) it,number) (grave number)
0 Name of Sexton or Person in Charge of Premises i• t , 1rnwf
Z c--a (pleaseiirint)
ILI
Signature Title 144°0k
DOH-1555(07/18)p 1 of 2
01.5005
Public Health Law Sec. 4145(2b)
Receipt
Human remains of " L delivered on ` , 20_G
Pine View Cemetery Representing the funeral home named on buriel permit
Official Funeral Directors Reg.or License#'f