Vaughn, Timothy •
NEW YORK STATE DEPARTMENT OF HEALTH ft 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Timothy G. Vaughn Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 8, 201 2 78 yrs. War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
Z City, Town or Village Ticonderoga Street Address Residential Healthcare
et et Manner of Death Undetermined Pending
Natural Cause El El ❑Suicide ❑ ❑
Circumstances Investigation
Lig Medical Certifier Name Title
Kathleen Pangia M.D.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
RIlli City, Town or Village Ticonderoga 1 564 40 9
❑Burial Date Cemetery or Crematory
❑Entombment 02/14/2012 Pine View Crematory
Address
Cremation Queensbury, New York
Date Place Removed
g El
� ` Hold
❑Removal and/or Held
and/or Address
Cl)=
0 Date Point of
0 Li Transportation Shipment
ci by Common Destination
Carrier
ni
❑Disinterment Date Cemetery Address•
g ❑Reinterment Date Cemetery Address
iliPermit Issued to Registration Number
Name of Funeral Home Sullivan, Minihan & Potter 01 646
Address
407 Bay Road, Queensbury, New York 12804
ig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
It
` 'Permission is hereby granted to dispose of the human re ains described above as indicated.
ii Date Issued 2/1 0/201 2 Registrar of Vital Statistics ` ("rh
(signature)
Niii District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
f Date of Disposition c,, ILA Toil Place of Disposition i.40,�, 4c,,,,,._
(address)
111
Uli
iM (section) (lot number) t� (grave number)
et Name of Sexton or Peron in Charg of Premises t��r�ty J e� C�
Ch.
� � (please print)
4.::,::,.:,::,::,, Signature Title CC-FAA-TO&
(over)
DOH-1555 (02/2004)