Taylor, Fred NEW YORK STATE DEPARTMENT OF HEALTF_ it SS
Vital Records Section Burial - Transit Permit
Name First ' X Middle ` - - Last S,eic
LO A_ i I v I a 1.....e.
Date of Death Age If Veteran of U. Armed Forces,
1 ole/3 er7 War or Dates LAI LJ /—i
- - if Death Hospital, Institution or L�
jCity, T iwn or Village�ur,c1,, t'`` � Street Address tj-� SLR H. 6.. .
0 1,1% =- er of Death Natural C se Acci eQ nt 0 Homicide 0 Suicide Un �Zt rmined ri Pending
Circ mstances Investigation
W Medical Certifier Name Title
0 R i V -T- --b—z AO
Address
31 L&u re,c, s-6, cif'i.). A, Y. J R.CO 6
i< Death Certificate Filed District Number Register Number
s
�,lfown or Village . • s F4R1 F OGA spR6AtC5
:Burial Date Cem ry or Crematory / -�a/`1/ a /a a l3 e'h-GV c.�.., lam^ e,- /
.❑Entombment Address
1JCremation OLA (--Gt.SbLAt , Ivy `J�r7C-
Date (� ; Place Removed
Z Removal �\// and/or Held
iR. ❑and/or
Hold Address
U)
O Date Point of
TransportationShipment
pmen
SS❑ .
0 by Common Destination .
Carrier
Q Disinterment Date Cemetery Address •
Q Reinterment •
Date Cemetery Address
Mil Permit Issued to Registration Number
iffl Name of Funeral Hor d s nor t_ /-(_ ) ,Lr—` GCS 91
Addresslik s/
el ,44.,,...,Aye_ (-,,,- ,...\.„...,: —a r , 3 A-L___
illi Name of Funeral Firm Making Disposition or to Whori4
1- Remains are Shipped, If Other than Above
2 Address
la
fl' Permission is hereby granted to dispose of the human remain ribed above as indicated.
Date Issued 1/2 S/ 2s 13 Registrar of Vital Statistics
/ (signature)
District Number 4 co/ Place S ;RATOGA SPRINGS
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I-3i-t3 Place of Disposition 1utV4,J C ith_.
2 (address)
iii
(section) (lot numb (grave number)
Name of Sexton or Person in Charg of Premises t•liM! ,",dit•
z • 1 (please print)
? Signature Title C111*n tit
(over)
DOH-1555 (02/2004)