Taylor, Reuban NEW YORK STATE DEPARTMENT OF HEALTH It Z‘)
Vital Records Section , ► Burial - Transit Permit
Name First Middle Last Sex
r °,- Reuban John Taylor Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 21, 2012 53 War or Dates
wPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Natural Cause ElAccident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
Erick Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District:. Nurrel RegisttD(er, umber
City, Town or Village �� ))
❑Burial Date Cemetery or Crematory
May 23, 2012 Pine View Crematorium
, ❑Entombment
Address
'Cremation Quaker Road Queensbury,NY 12804
4 Date Place Removed k d
ti❑ Removal and/or Held
and/or Address
Hold
' Date Point of
CTransportation Shipment
, ' by Common Destination
El Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
I I Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
4:4-
ill
, ,• Permission is hereby granted to dispose of the human remains descr' e a. ove in d.
Date Issued (J:i Z3/20/L Registrar of Vital Statistics
(signature)
lf/ `fs`/,
District Number Place ` �lr
F—` I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
uj• Date of Disposition OM(0- Place of Disposition F4.40 Lew Core.(-6 rt.�
(address)
w
CO
Ce (section) n (lot number) c ,n (grave number)
0 Name of Sexton or Per on in Charge Premises (.hr)5A-- r "Zvi`tn
(please print)W Signature Title Cr in FITOn
(over)
DOH-1555 (02/2004)