Washburn, Jill # 33y
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ' Burial - Transit Permit
Name First Middle Last Sex
Jill E.Washburn Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/21/2018 76 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death p Natural Cause ❑Accident El Homicide Ei Suicide 0 Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Rodney Ying MD
X Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 243
El Burial Date Cemetery or Crematory
04/24/2018 Pineview Crematorium
Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
". Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
is 7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/23/2018 Registrar of Vital Statistics John rn'Franck(cE(ectronicaltySigned)
(signature)
District Number 4501 Place Saratoga Springs, New York
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
': Date of Disposition I IZS`l Place of Disposition � j (ryrnp�rlr,ry..
(address)
(section). (lot numbe (grave number)
• m of or Person in Charge of Premises 71,3t. 4Na e Sexton 9 , ( se print)
a Signature Title 11 I)tk 4.
(over)
DOH-1555 (02/2004)