Lewis, Daniel George NEWIF Zd,�
YORKSTATELOF DEPARTMENT Burial • Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Daniel George Lewis Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/19/2022 46Years War or Dates
IF— Place of Death Hospital.Institution or
Z City,Town or Village Glens Falls Street Address 10 Goodwin Avenue,Glens Fails,New York 12801
Manner of Death ElNaturalCause Accident Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
III
WMedical Certifier Name Title
O Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Fails District Number Register Number
Ci ,Town or Village 5601 174
Burial Date metery,Crematory or Facility Name
03/25120 Pyre View Crematorium
Entombment Address Ce
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
Hold Address
VTransportation Date Point of
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El Re interment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
G. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/23/2022 Registrar of Vital Statistics Alvan Nam(Eh tmnua*Srgrud)
/signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
a Date of Disposition . 1$Ill. Place of Disposition t rUr_jiLc.
d ess/
iW
CO
CIC (section) / j umtrer/Q (grape numbed
Name of Sexton or Person in Charge of Premises `'"G" `r— .S i`fr
(please Pro t)W /4
Signature ' �' Title ` M^�
DOH-1555(07/18)p i of 2
�a M 1... 6
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#