Lewis, Ricky Allan •
LF
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ricky Allan Lewis Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/27/2022 68 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Lake Luzerne Town Street Address 1754 Call Street, Lake Luzerne Town, New York 12846
p Manner of Death El Natural Cause Accident Homicide OSuicide Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
John Weinhold MD
Address
1300 Massachusetts Avenue,Troy,New York 12180
Death Certificate Filed Town Of Lake Luzeme District Number Register Number
City,Town or Village 5656 21
Burial Date Cemetery,Crematory or Facility Name
® 08/31/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d. Date Point of
Cl) Transportation
CI by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment 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
1— Remains are Shipped,If Other than Above
a Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/31/2022 Registrar of Vital Statistics Cynthia Sherwood-(ECectronicallySigned)
(signature)
District Number 5656 Place Town Of Lake Luzerne
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
Z Date of Disposition Q13j I Z 7 Place of Disposition ?Al
2 (address)
W
N
CC (section) hlot number (grave number)
gName of Sexton or Person in Char Premises r�
Z
please print) /'
W Signature Title ` p'_
DOH-1555(07/18)p 1 of 2
^f .. s
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# '