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Vaughan, Grace T
oq , ... ..: tio-D NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Grace T.Vaughan Female Date of Death Age If Veteran of U.S.Armed Forces, 02/20/2024 70 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Town Street Address 104 Deweys Bridge Road,Fort Ann Town,New York 12887 W Manner of Death Undetermined Pending W Natural Cause Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title G Vicky Campbell Coroner Address 1517 COUNTY RTE 31,Granville,New York 12832 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 3 Burial Date Cemetery,Crematory or Facility Name 02/27/2024 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address CO 0 A. Date Point of Cl)OTransportation p by Common Shipment Carrier Destination O Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 2 Address CC W A. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/27/2024 Registrar of Vital Statistics Miranda.7ferrings(iaw(ECectronicattySigned) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 2 01 Z ii Place of Disposition 'T (,W4acTPLP-s, a (address) W NCC (sedan) I (lot number) (grave number) gName of Sexton or Person in Charge of .cmises f?f Z7 (pleJse print) W Signature - Title [kWh( DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial;permit Official Funeral Directors Reg.or License#