Vaughn, Floyd NEW YORK STATE DEPARTMENT OFHEALTH ��U��^��N ~ ���%�8�*�~� Q�r����~�
VbaRecords Sa��n �~~~~ ^~~~ ~ ~ ~~^ ^~~~~ Permit
Name First Middle Lost Sex
Flo d
---'0���----' --
Date of "e""' "y" If ,e^"'"'' of U.S. "'"=" Forces,
War or Dates no
Z Place of Death Hospital, Institution or
:.Uj City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
-1111. Manner of Death o Undetermined E] Pending
Natural CauseE] Accident []Homicide E] Suicide
Circumstances Investigation
Medical Certifier Name Title
LU
James David _SohwonkarMD
......................._............................................
Address
90 South Street. Glens Falls N.Y. 12801
~^^^--~
Death Certificate Filed District Number Register Number
City of Glens Falls
City,Town or Village
Date Cemetery or Crematory
ElBurial March 5, 1994 Pine View Cemetery
Cremation Address Queensbury, New York
2: Date Place Removed
2 E] Removal and/or Held
Address
cn
13L Date Point of
0: E]Transportation by Shipment
Destination
El Disinterment Date Cemetery Address
Reinterment Date - Cemetery Address
Registration Number
Permit Issued to
Name of Funeral Firm Regan and Denny Funeral Service, Inc. 01583
Address
26 Quaker Road, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb ranted to dispose of the human re a s described above as indicated.
Da
telssued Registrar of Vital Statistics oe'_
70 /
- Place
District Number, It
|certify that the remains of the decedent identified above were disposed ofin accordance with this permit on:
Date ofDisposition 5/25/94 Place cfDisposition Pine \/ievv Cemetery Queeusburl/ 0Y 12804
M (address)
Bod000 #I I3—E l
(section) (lot number) (grave number)
cc
Name of8ox� P in Charge n|Premises Rodney G. Mosher
z (please print)
U.1 Signature k-h-- Title Supt.
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