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Taylor, Wyatt r27 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Wyatt Monty Taylor Male Date of Death Age If Veteran of U.S. Armed Forces, February 11, 2017 39 War or Dates Place of Death Hospital, Institution or City, Town or Village Argyle Street Address 4837 County Route 48 Oni Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined X❑ Pending Circumstances Investigation W Medical Certifier Name Title 1 James Gariepy, Address 19 East Broadway Salem, NY 12865 Death Certificate Filed District Number S� Register Number City, Town or Village Argyle S LI ❑Burial Date Cemetery or Crematory February 14, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077 Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped, If Other than Above • Address re Ow Permission is hereby granted to dispose of the human remains described above as indicated. sry Date Issued )\11 I I—) Registrar of Vital Statistics 4d, *L ie-eiN ,- (signature) District Number S-L5ta Place anciyL kki I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: • Date of Disposition 02/44,12017 Place of Disposition Quaker Road Queensbury,NY 12804 //2 ter,�;�'L-P l�I. .,,-,� (address)LA / LIE (section)\ / (lot number) / (grave number) CIName of Sexton or r_sorL 9harge of Premises J LA /1 G44 1 L X=t G !i i i7 (= (please print) � Signature , /,A,, ),,G L--�"""'__ Title < !2/11-../ay 6te'``G.¢0,/_- r / (over) DOH-1555 (02/2004)