Taylor, Thomas k NEW YORK STATE DEPARTMENT OF HEALTH ,;;:. ; # kV.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Taylor Male
Date of Death Age If Veteran of U.S. Armed Forces,
09 / 21 / 2016 52 War or Dates Yes 1986-1988
}: Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
. ManitOr of Death®Natural Cause 0 Accident 0 Homicide E Suicide -1 Undetermined Pending
'W. Circumstances Investigation
LI
uj Medical Certifier Name Title
Q Asim Chaudry MD
Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Numbera Register Number
87
City, Town or Village Glens Falls
1LiBurial Date Cemetery or Crematory
09 / 27 / 2016 Pine View Crematory
iiiiii.ii El Entombment Address
ECremation Queensbury, NY
Date Place Removed
Z.❑Removal and/or Held
and/or Address
V
Hold
VIA Date Point of
0 Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date AR
Cemetery Address
ilig Permit Issued to Registration Number
ril Name of Funeral Home Compassionate Funeral Ca 00364
Address
Mi 402 Maple Ave., Saratoga Sp., 12866
ri Name of Funeral Firm Making Disposition or to Whom
4 Remains are Shipped, If Other than Above
Address
CC
UI
Permission is her by anted to dispose of the human rains ains d scribed a ove as Indic
Ril Date Issued (�q' , � /fiegistrar of Vital Statistics ` o77-C
iiil (signature)
District Number 6-60 j Place Gle s Falls , New York
.`` I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
#-
fil-tu c
Date of Disposition � I Li IN Place of Disposition 1cw Sm rW,--
2 (address)
iti
fil
2 (section) / (lot number) (grave number)
i Name of Sexton or Person in Charge Premises lens :- St of ii
2 lease print) •
04 Signature et Title Ca folin
•
(over)
DOH-1555 (02/2004)
6