Newton, Thomas Vaugh Sr. '---qa:F 4 /CIO
NEW YORK STATE DEPARTMENT OF HEALTH / Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Vaughn Newton Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/11/2022 91 Years War or Dates 1954
H, Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined 0 Pending
� � Natural Cause �Accident �Homicide �Suicide
W Circumstances Investigation
U Title
W Medical Certifier Name
O Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 102
❑Burial Date Cemetery,Crematory or Facility Ne
02/14/2022 Pine View Crematorium
n Entombment —
Address
X❑Cremation Queensbury Town,New York
❑Donation
H
Date Place Removed
Removaland/ and/or Held
or
CO
Hold Address
0
0. Date Point of
U) n Transportation Shipment
p by Common
Carrier Destination
n Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67, Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
Address
CC
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/14/2022 Registrar of Vital Statistics Megan Noliin(ECectronicaliy,Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— 1'
Z Date of Disposition ZIgti 121 Place of Disposition MtY...wwZoi[6.. ..
W (address)
W
U)CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of remises
h
Z (pleas riot)
W Title � _F !PC
Signature
DOH-1555(07/18)p 1 of 2
015642
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#