Taylor, Clarence Lee # 3ig,
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Clarence Lee Taylor Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/03/2023 92 Years War or Dates 1951-1955
H Place of Death Hospital,Institution or
Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
Iw Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
CI Joshua Starteri NP
Address ID
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 25
EBurial Date Cemetery,Crematory or Facility Name
05/05/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0Z❑Removal Date Place Removed
and/or and/or Held
I Hold Address
N
0
CL Date Point of
(/)ElTransportation
p by Common Shipment
Carrier Destination
O
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward, New York 12828
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
g Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/04/2023 Registrar of Vital Statistics Jenny Linda M Martefle(ECectronica((ySigned)
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: j
~ Z,--Z Date of Disposition 475 �Z3 Place of Disposition �,�„
W
2 (ad ress)
W
CCCC (section) /j (lot number) (grave number)
0 Name of Sexton or Person in Charge of Pr mises L.— ii
Z 'IpIease print/
W Signature Title [ "it
DOH-1555(07/18)p 1 of 2
I .ri 94 7
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# ;,_