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Manchester Jr., Wendell NEW YORK STATE DEPARTMENT OF HEALTH a ! 353 Vital Records Section j Burial - Transit Permit Name First Middle Last Sex Wendell Carol Manchester, Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, May 15, 2017 76 War or Dates Vietnam Place of Death Hospital, Institution or City, Town or Village Street Address Manner of DeathEli Natural Cause ❑ Accident ❑ Homicide ❑ Suicide El Undetermined El Pending " Circumstances Investigation Medical Certifier Name Title Robert L Evans DO, Address 1 Irongate Center Glens Falls, NY 12801 .T Death Certificate Filed District Number _ Register Number City, Town or Village �5�� fj 5.3 0 Burial Date Cemetery or Crematory May 22, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held t,, and/or Address Hold Date Point of :x 0 Transportation Shipment 'i' by Common Destination Carrier 4 1.! El Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address " Permit Issued to Registration Number 4. Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Ti Permission is hereby granted to dispose of the human remains described above as indicated. 4 Date Issued 6) i 8)/7 Registrar of Vital Statistics iL4J2 X t' - .-4 (signature) District Number t j5(o Place 7601 rrf e 4," I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 05/22/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises Lr r ��+�►!� ( ease print) " Signature ti iir Title altftrlik (over) DOH-1555 (02/2004)