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Manley, David Clinton NEWYORK STATE DEPARTMENT OF HEALTH .�.. Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David Clinton Manley --TMale Date of Death Age If Veteran of U.S.Armed Forces, 04/02/2020 77 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 153 Dubes Road,Kingsbury Town,New York 12839 LU p Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Pending C.) Circumstances Investigation LU Medical Certifier Name Title Joseph Mi hind ukulasuriya MD Address 20 Murray Street,Glens Falls,New York 12801 Death Certificate Filed F5762 gister Num ict Number Reber City,Town or Village Kingsbury Town 10 Burial Date Cemetery,Crematory or Facility Name 04/06/2020 Pine View Crematorium Entombment Address IX 1 Cremation Queensbury Town,New York ❑Donation C) ❑Removal Date Place Removed and/or and/or Held H U) Hold Address O d Date Point of U) ElTransportation p by Common Shipment Carrier Destination Disinterment 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 orto Whom Remains are Shipped,If Other than Above 2 Address W W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/06/2020 Registrar of Vital Statistics Cynthia Bardin(ECectronicadCySigned) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F � Z Date of Disposition ghtlA Place of Disposition IL t'bv (address) W U) ir (section) ( (lotnum / (grave number) 0 Name of Sexton or Person in Charge of Premises Z ase print)r 111 Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) '" 0 1 E J 8- Receipt Human remains of delivered on , 20 s 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#