Taylor, Philomena Ann t
INEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Philomena Ann Taylor Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/23/2020 86 Years War or Dates
p Place of Death
Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
ILJ
p Manner of Death 0 Natural Cause ❑Accident D Homicide ❑Suicide E Undetermined u Pending
W U Circumstances Investigation
W Medical Certifier Name Title
C1 John Tietjen DO
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 2531
❑Burial Date Cemetery,Crematory or Facility Name
11/25/2020 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
ElDonation
(s E Removal Date Place Removed
and/or and/or Held
t— Hold Address
CO
0
d Date Point of
U) ❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/24/2020 Registrar of Vital Statistics DaniellSctlii.pre(E/ctronicallySigned)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Il—
Z Date of Disposition Hi 17i ZO Place of Disposition .W.11,— A---
2 (address)
W
NCC (section) ;lot number) (grave number)
0 Name of Sexton or Person in Charge of P 'ses 1 9 Wt 4ti IT
Z (pleaselorint)
W Si nature Title Yl
g
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) _ 1 4 7'3 3
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#