Taylor, Cynthia J. Y6
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cynthia J.Taylor Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/05/2021 79 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Indian Lake Town Street Address 154 LaVergne Road, Indian Lake Town, New York 12842
W Manner of Death 0 Undetermined ❑Pending
Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
Kate Sauer-Jones PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Indian Lake 2053 9
❑Burial Date Cemetery,Crematory or Facility Name
08/06/2021 Pine View Crematory
Entombment Address
IDCremation Queensbury Town,New York
❑Donation
ElRemoval Date Place Removed
and/or and/or Held
Hold Address
0
0- Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake, New York 12842
Name of Funeral Firm Making Disposition or to Whom
i` Remains are Shipped,If Other than Above
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/06/2021 Registrar of Vital Statistics Julie A Clawson(Electronically Signed)
(signature)
District Number 2053 Place Indian Lake, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /`,�
Z Date of Disposition g 11( 14 Place of Disposition µ [.✓lor,,....,_
11.1
2 (address)
LU
CC N
(section) /lot number) (grave number)
GName of Sexton or Person in Charge of mises AW & tntoillt
W /p! e print/ /PO
Signature Title h
DOH-1555(07/18)p t of 2
3
501
Public Health Law Sec. 4145(2b) 1"
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#