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Manley, William Terry NEW YORK STATE DEPARTMENT OF HEALTH II 7o._ Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William Terry Manley Male Date of Death Age If Veteran of U.S.Armed Forces, 02/22/2024 46 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 32 Manley Way, Kingsbury Town,New York 12839 CU p Manner of Death E Natural Cause Accident El Homicide ESuicide ❑Undetermined Pending W Circumstances Illnvestigation W Medical Certifier Name Title CI Thomas Vincent Coroner Address 383 Broadway BLDG B,Fort Edward,New York 12828 Death Certificate Filed Town Of Kingsbury District Number Register Number City,Town or Village 5762 6 Burial Date Cemetery,Crematory or Facility Name 02/26/2024 Pine View Crematory Entombment — Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed - and/or and/or Held H- Hold Address N 0 d Date Point of U) Transportation Q by Common Shipment Carrier Destination o Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 E... Remains are Shipped,If Other than Above 5 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/26/2024 Registrar of Vital Statistics Cynthia cBardin g(ectronicaCCySigned) (signature) District Number 5762 Place Town Of Kingsbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l- 2 Date of Disposition ZI74 174 Place of Disposition frmivrti Cie c w,v _ 2 (address) W NCC (section) �n (lot number) (grave number) 0 Name of Sexton or Person in Charge of P es ^` �.. � Z ..,4/. (plse print) W Signature Title DOH-1555(07/18)p 1 of 2 r y g P. r).3h 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#