Lewis, Kimberly Ann NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kimberly Ann Lewis Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/04/2023 53 Years War or Dates
ll— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
11.1
• Manner of Death pi Natural Cause Accident Homicide Suicide []Undetermined Pending
W I I I 'Circumstances Investigation
W Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 563
Burial Date Cemetery,Crematory or Facility Name
12/06/2023 Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
Donation
O I I Removal Date Place Removed
and/or and/or Held
1 Hold Address
N
0
d Date Point of
Cl)El Transportation Shipment
p by Common
Carrier Destination
El
Disinterment
Date Cemetery Address
n Date Cemetery Address
I I Reinterment
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
F. Remains are Shipped,If Other than Above
5 Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/05/2023 Registrar of Vital Statistics Megan.Noun(ECectronicalTySigned)
(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:
H
Z▪ Date of Disposition 174$10 Place of Disposition I j iE rs,,� `C1' T.
2 (address)
W
cc (section) tot number) ;grave number)
el Name of Sexton or Person in Charg f Premises 1
(pleas print)
tL ft7Signature Title ���L
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b) "I
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#