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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Katherine M. Taylor Female
4 Date of Death
Tsti-
Age If Veteran of U.S. Armed Forces,
January 10, 2014 26 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address
Manner of Death Natural Cause X❑ Accident 111 Homicide El Suicide El Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
, City, Town or Village Kingsbury 5' 7 . ) G.2-
a ❑Burial Date Cemetery or Crematory
January 13, 2014
❑Entombment Pine View Crematory
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
xt
z Reinterment Date Cemetery Address
x
,a
ri Permit Issued to Registration Number
;: Name of Funeral Home M. B. Kilmer Funeral Home 01077
! Address
arl
123 Main St., Argyle NY 12809
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 remains described above as indicated.
Date Issued op,/3-,�0/y Registrar of Vital Statistics_ eyi,±4� Ct f it, , ,
/ (signature)
District Number 5 7 6 Place 7(/ it 0 f kiA`S IJUr(�
A- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/13/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) _ (Iqt number)�+ (grave number)
Name of Sexton or Person incharge of Pre ises /to l/9r- JtN,,.at
/1 please print)
Signature I1 i5
g Titlekm►�
(over)
DOH-1555 (02/2004)