Washburn, Michael S. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael S Washburn Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/04/2020 67 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
LU
p Manner of Death X❑Natural Cause ❑Accident I=1 Homicide ❑Suicide Undetermined Pending
W U Circumstances Investigation
GMedical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 454
EiBurial Date Cemetery,Crematory or Facility Name
10/07/2020 Pine View Crematory
0 Entombment Address
iCremation Queensbury Town,New York
❑Donation
o ❑Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
O. Date Point of
fA ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/07/2020 Registrar of Vital Statistics 9p6er#Andrew Curtzr(Ekctronica/T 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:
2
W Date of Disposition loiq)Zo Place of Disposition
2 (address)
W
N (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premi s IL.- QMA4I1+
se print)
W Signature Title
DOH-1555(07/18)pi of 2
r
Public Health Law Sec. 4145(2b) 014078
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#