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Manley, David Wayne NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David Wayne Manley Male Date of Death Age If Veteran of U.S.Armed Forces, 04/29/2020 58 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 W p Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation V W Medical Certifier Name Title Joseph Mi hind ukulasuriya MD Address 20 Murray Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 15 Burial Date Cemetery,Crematory or Facility Name 05/01/2020 Pine View Crematorium Entombment Address RICremation Queensbury Town,New York ❑Donation ZO Removal Date Place Removed and/or and/or Held ~ Hold Address N O d Date Point of CO) ❑Transportation 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 or to Whom I.— Remains are Shipped,If Otherthan Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/01/2020 Registrar of Vital Statistics Cynthia rdardin(ECectronicaCCy Signed) (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: H Z Date of Disposition 6-1-2p 2e7 Place of Disposition a2ie' -, e LU (address) or W W 'Section) number) (grave number) Name of Sexton or Person' C rem' es �''�? o � ��m t (please print)Z W Signature Title DOH-1555(07/18)p 10 Public Health Law Sec. 4145(2b) 4 013 6 6 Receipt Human remains of delivered on , 20 r, Pine View Cemetery Y Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# '