Mantice, Michael George ( LF)
NEW YORK STATE DEPARTMENTOFHEALTH ---�- Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael George Mantice Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/23/2022 63 Years War or Dates Vietnam
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 78 Alpine Avenue,Queensbury Town,New York 12804
EManner of Death El Natural Cause EAcci El Homicide OSuicide ❑Undetermined ❑Pending
W Circumstances Investigation
uJ Medical Certifier Name Title
Oi Eileen Spinelli NP
Address
Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury, District Number Register Number
City,Town or Village 5657 158
EIBurial Date Cemetery,Crematory or Facility Name
10/25/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
~
to Hold Address
0
Lt. Date Point of
{p❑Transportation Shipment
p by Common
Carrier Destination
ODisi nterment
Date Cemetery Address
Date Cemetery Address
El Re interment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
5 Address
IX
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/25/2022 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(signature)
District Number 5657 Place Town Of Queensbury
!certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition /0I A:I Z2 Place of Disposition h V� �.4pr�
2 (ad&ess)
re W �� �
U) /j(section) Ifatnumbei/ ( `""""- l,4raem number)
GName of Sexton or Person in Charge emises ° `'
Z /ple print/
W Signature Title /Fm.aiZ'C
DOH 1555(o7/18)p Id 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#