Lewis, Charlotte Ann r—(1.7.F)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charlotte Ann Lewis Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/27/2022 82 Years War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Moreau Town Street Address 271 Fort Edward Road, Moreau Town,New York 12803
p Manner of Death Il Natural Cause Accident [IIHomicide Suicide Undetermined []Pending
C.) Circumstances I 'Investigation
W Medical Certifier Name Title
0 Mark Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 59
Burial Date Cemetery,Crematory or Facility Name
11/30/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Date Point of
U)❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
riDisinterment
riDate Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped,If Other than Above
3 Address
CC
W
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
g
Date Issued
11/29/2022 Registrar of Vital Statistics Leeann McCabe(Electronically Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Cr � 4----
111
Date of Disposition )Z�Z�t2 Place of Disposition `1(address)
2
uJ rave number/
(p (section) /�(lot number) (g
cC �L. tt
gName of Sexton or Person in Charge of Premises (ple*eprint)
'41
Ili Signature Title �(
DOH-1555(07/18)p t of 2
446
Public Health Law Sec. 4145(2b)
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#