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Lewis, Michael Joseph
-lit fil cloof NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Joseph Lewis Male Date of Death Age If Veteran of U.S.Armed Forces, 12/30/2023 73 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village South Glens Falls Village Street Address 47 Harrison Avenue 310,South Glens Falls Village,New York 12803 IIIJ p Manner of Death 12gNatural Cause Accident El Homicide Suicide nUndetermined nPending f ,Circumstances I 'Investigation W Medical Certifier Name Title CI Mark Quaresima MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Village Of South Glens Falls District Number Register Number City,Town or Village 4524 23 Burial Date Cemetery,Crematory or Facility Name 01/03/2024 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed and/or and/or Held H Hold Address W 0 C. Date Point of U)❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address Disinterment El Reinterment Date Cemetery Address 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 H Remains are Shipped,If Other than Above g Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/03/2024 Registrar of Vital Statistics Samantha Berg(Electronically Signed) (signature) District Number 4524 Place Village Of South Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 11y(let Place of Disposition FTpf r►1C,-) (Pc Th4-1141.-- ILI 2 (address) W COtr (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premisq" d " \ f (p ase print) nt) ` Ili *PATitle ` l31 DOH-1555(07/18)p 1 of 2 3 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#