Washburn, Lorri 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
2 _ Name First Middle Last Sex
Lorri Jayne Washburn Female
Date of Death Age If Veteran of U.S. Armed Forces,
.- May 19, 2016 59 War or Dates
ce of Death Hospital, Institution or
n
, Town or Village Glens Falls Street Address Glens Falls Hospital
rti Manner of Death 0 Natural Cause Accident El Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
Sean Bain, M.D. Dr.
Address
100 park St. Glens Falls, NY 12801
D h Certificate Filed District umber Register Number
k Ci Town or Village t.e r s lc \\S ' 2&
°`
'`a®Burial
Date Cemetery or Crematory
May 24, 2016 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Rd. Queensbury,NY 12804
ft Date Place Removed
Removal and/or Held
0 and/or Address
F i, Hold Pine View Cemetery
i Date Point of
Ili El Transportation Shipment
voi by Common Destination
Q Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
E4 Remains are Shipped, If Other than Above
, Address
WPPermission is herebygranted to dispose of the human remains described above as indicated.
€:, aP
Date Issued 5 f_2 3 ) ) Registrar of Vital Statistics tw 1. jv,
,_ (signature)
District Number (Do i Place �; (.r v-s v-0, S , N
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition 05/24/2016 Place of Disposition Quaker Rd. Queensbury,NY 12804
, (address)
Erie 32B 1
(section) (lot number) (grave number)
Name of Se on or Person in Charge of Premises Connie L. Goedert
(please print)
.r-
U' Signature, Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)