Manell, Michael t1-I,] -
NEW YORK STATE DEPARTMENT OF HEALTH /7
Vital Records Section Burial - Transit Permit
I Name First Middle Last Sex
Michael G. Manell Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 26, 2014 51 War or Dates
1- Place of Death Hospital, Institution or
LT) City, Town or Village Hudson Falls Street Address 25 Delaware Avenue
0 Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑Undetermined ❑ Pending
111
Circumstances Investigation
11J' Medical Certifier Name Title
a Darci Gaiotti-Grubbs, Dr.
ap ,
Address
102 Park Street Glens Falls, NY 12801
y
Death Certificate Filed District Number Register umber
--7 City, Town or Village �7a(0
❑Burial Date Cemetery or Crematory
July 29, 2014 Pine View Crematorium
❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
IIIRemoval and/or Held
} and/or Address
_p Hold -
Date Point of
a;❑Transportation Shipment
0 by Common Destination
In i Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
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
I Remains are Shipped, If Other than Above
• Address
Je
W
CL Permission is hereby granted to dispose of the human ream ' s described above as indicated.
Date Issued '7-01 fo' Registrar of Vital Statistics �y"` " (-,3
(si nature)
District Number_s-724, Place fags
I certify that the remains of the decedent identified above were disposed o in accordance with thi permit on:
W Date of Disposition 072014 Place of Disposition Quaker Road Queensbury,NY 12804 P44%014I(
(address)
in
(.0[ (section) (J I num bpr) (grave number)
44
O Name of Sexton Person arge of Premises5 l/��D5
W h (p/ease P " t) J
Signature Title ��
(over)
DOH-1555 (02/2004)