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Taylor Temple G. ILI NEW YORKSTATE DEPARTMENT OF HEALTH BUriat - Transit Permit Bureau of Vital Records Name First Middle Last Sex Temple G.Taylor Male Date of Death Age If Veteran of U.S.Armed Forces, 02/22/2020 87 Years War or Dates il.— Place of Death Hospital,Institution or Z City,Town or Village Indian Lake Town Street Address 7969 New York State Route 30,Indian Lake Town,New York 12812 LU p Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title 0 Christopher Jackson PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Indian Lake 2053 1 Burial Date Cemetery,Crematory or Facility Name 02/24/2020 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation z Removal Date Place Removed and/or and/or Held H usHold Address O G. Date Point of N Transportation Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above Address W t1 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/24/2020 Registrar of Vital Statistics Julie A Clawson(Electronically Signed) (signature) District Number 2053 Place Indian Lake, 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 Z.175'110 Place of Disposition r W (address) 2 W N (section) /J (lot number) (grave number) 0 Name of Sexton or Person in Charge of remises (P se print) Z u j Signature Title DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt 1 Human remains of delivered on , 20 VI- Pine View Cemetery RepresFnting th e he funeral home named on burial permit Official Funeral Eirectors Reg.or License#