Hayes Jr., Manley NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Manley James Hayes Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/03/2018 74 Years War or Dates 1961-1964
g Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Garnet Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
e Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 123
'' Burial Date Cemetery or Crematory
03110/2018 Pine view Cemetery
❑Entombment Address
❑Cremation Queensbury Town, New York
4-1 Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
it7- Carrier
''i, Q Disinterment Date Cemetery Address
p}E.
Reinterment Date Cemetery Address
Permit Issued to Registration Number
, Name of Funeral Home Carleton Funeral Home Inc 00281
Address
Ai 68 68 Main Stpo Box 67,Hudson Falls,New York 12839
,a,
::' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
»
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/07/2018 Registrar of Vital Statistics Iofiert 1 Curtis IEkctronar. :ySrgne4)
(signature)
District Number 5601 Place Glens Falls, New York
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ) 1012 01 f Place of Disposition Z I (ua.12th I?J,. �r�,(4,e6
?ALL (address)
t 33 I b i
ct (se on) / _ (lot number) (grave number)
Name of Sexton or Person in Charge of Premises LbFJ µ1�' L. lx0:x3P-4
4 4 (p se;vrint)
'a Signature n-Il-tl. Title�� �KTiGti
QAtt.
(over)
DOH-1555 (02/2004)