Washburn, William # (NEW YORK STATE DEPARTMENT OF HEIALTH �2
Vital Records Section Burial - Transit Permit
It
'. Name First Middle Last Sex
William Washburn Male
Date of Death Age If Veteran of U.S. Armed Forces,
:_ June 21, 2011 78 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Cambridge Street Address 2038 State Route 22
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
t Medical Certifier Name Title
P .,` Matthew C. Pender,
Address
1 Myrtle Ave. Cambridge, NY 12816
Death Certificate Filed District Number Register1umber
City, Town or Village '�c,o! J
g ❑Burial Date Cemetery or Crematory
a June 22, 2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
TO and/or
Hold Address
Date Point of
❑Transportation Shipment
by Common Destination
A Carrier
A. ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
Address
123 Main St.,Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the humangrains descri above • : ,- ated.
Date Issued Idol I Registrar of Vital Statistic ' .-,f! '`CIA'
(si.j Lure)
District Number 51up I Place 60���� ?�%�,c f,� had/ e-i ibis /`� / /�io,5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/22/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Ss Name of Sexton or Pe on in Charg of Premises n,�, t rK lir
(please print)
Signature Title OK'JWtOL
(over)
DOH-1555 (02/2004)