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Vaughn, David Kenneth NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David Kenneth Vaughn ,. Male Date of Death Age If Veteran of U.S.Armed Forces, 02/11/2024 76 Years War or Dates 1965-1967 H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ZNatural Cause Accident ❑Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title 0 Gwendolyn Moms-Dickinson PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 85 — Burial Date Cemetery,Crematory or Facility Name ......' 02/13/2024 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York DDonation ZZ❑Removal Date Place Removed - and/or and/or Held H- Hold Address N 0 0. Date Point of U)❑Transportation Shipment (71 by Common Carrier Destination DDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/12/2024 Registrar of Vital Statistics Megan.No(in(ECectronica1Ty Signed) (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: Z Date of Disposition z I fl 2 N Place of Disposition `ts;, l'il�F,m ,,T LU 2 (address) W Cr (section) (lot number (grave number) 8 Name of Sexton or Person in Charge of P, ises 2 ,fr Z j lease print W Signature Title DOH-1555(07/18)p 1 of 2 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#