Taylor, Michael Anthony Sr. ,r . '''1 ,3-.
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle
Last I Sex
Michael Anthony Taylor Sr
Date of Death Male
06/30/2022 I Age If Veteran of U.S.Armed Forces,
61 Years War or Dates
1,_ Place of Death
City,Town or Village Hospital,Institution or
g Glens Falls Street Address 43 Ridge Street Apt 712,Glens Falls, New York 12801
Manner of Death ID
Natural Cause Accident
W Homicide Suicide Undetermined ❑Pending
V Circumstances
G Medical Certifier Name Investigation
Title
William Parker MD
Address
9 Carey Road,Queensbury Town,New York 12804
DeEath Certificate Filed City Of Glens Falls District Number
City,Town or Village I
5601 Register Number
Date j347
Burial Cemetery,Crematory or Facility Name
07/01/2022 Pine View Crematory
Entombment
Address
IICremation Queensbury,New York
Donation
oz❑Removal Date Place Removed —
p and/or I and/or Held
Hold Address
0
O. Date Point of
CO❑Transportation
O by Common Shipment
Carrier Destination
IDDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Name of Funeral Home Singleton Sullivan Potter Funeral Home Registration Number
01596
Address
: 407 Bay Rd,Queensbury,New York 12804
,,;,, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
lU
Permission is hereby granted to dispose of the human remains described above as indicated.
1 Date Issued 07/01/2022 Registrar of Vital Statistics Megan Arofm(ElectronicafySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t. Date of Disposition 72-101 Z. Place of Disposition -- 'Up V`G•+J C repik h
,..3
k.< (address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge remiss A Yili 0v1) r:)Ct6
(please print)
Z
W Signature Title r
DOH-t555(o7118)p 1 of 2
} y`y tl
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#