Taylor, Lillian NEW YORK STATE DEPARTMENT OF HEALTH 1 # 710
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lillian _ Taylor Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 2/20/201 4 93 yrs. War or Dates no
}4 Place of Death Hospital, Institution or
Z City, Town or Village Fort Ann Street Address 1 429 Patten Mills Rd.
Manner of Death❑Medical Certifier
Natural Cause ❑Accident El Homicide ❑Suicide El Undetermined Pending
Circumstances Investigation
Name Title
David Foote MD.
Address
Death Certificate FiledMai St. , Hudson "uistrict Number 2839 Register Number
iiiili City, Town or Village Fort Ann 5754 / Zt
Date Cemetery or Crematory
Burial Dec. 22, 2014 PineView Crematorium
Address
®Cremation Queensbury, NY. 12804
FDate Place Removed
0❑Removal and/or Held
and/or Address
Hold
Date Point of
ui❑Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
": Permit Issued to Mason Funeral Home Registration Number
Name of Funeral Home 01 1 1 7
€€ Address
P.O. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem described above as` rydicated.
>€ Date Issued /a�)/;QQ'/y Registrar of Vital Statistics ,L/4 " _44� J,�> l/j/r Z-2
kii (signaf�e) ^
iiiiiiiiii District Number 57 54 Place �?ir1-�� �% C - 7 /Z 2-7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F gW Date of Disposition izra-IN Place of Disposition 1iw or,..,
2 (address)
Lu
(/)
CC (section) ot-number) c (grave number)
GName of Sexton or Person in C arge of Premises rt, i..- Argil
g (please print) I
W Signature Title C1746-11
(over)
DOH-1555 (9/98)