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Lewis, Aaron Edward NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Aaron Edward Lewis Male Date of Death Age If Veteran of U.S.Armed Forces, 08/19/2021 37 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 12 Hicks Road,Queensbury Town,New York 12804 uQ Manner of Death ❑Natural Cause ❑Accident Homicide ❑Suicide Ell Undetermined 0 Pending ✓ Circumstances Investigation W Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 174 ©Burial Date Cemetery,Crematory or Facility Name 08/27/2021 Pine View Cemetery ❑Entombment Address ❑Cremation Queensbury Town,New York ❑Donation 0 ElRemoval Date Place Removed and/or and/or Held N Hold Address 0 d 1-1 Date Point of Cl) ❑Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/24/2021 Registrar of Vital Statistics Carolinexkligarie Barber(E/ctronica(Srgned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 'Z Date of Disposition 8/27/2021 Place of Disposition 21 Quaker Rd. Queensbury, NY 12804 11.1 2 (address) W Mohican 32 F 1 CC (section) (lot number) (grave number) 8 Name of Sex r Person in Charge of Premises Connie Goedert (please print) • Signature Title Superintendent DOH-1555( /18)plof2 I Public Health Law Sec. 4145(2b) 012869 Receipt Human remains of 1 , ; , delivered on , , 20 e Pine View-Cemetery — Representing`the funeral home named on burial permit Official Funeral Directors Reg.or License# ,•` LEWIS NAME Aaron Edward Lewis Age: 37 Lot Owner: Marion King Lot# Mohican Lot 32 # F Grave# 1 Case: Concrete Died: 8/19/2021 Interred: 8/27/2021 Funeral Home:Singleton Sullivan Potter Cemetery: Pine View