Washburn, Tammy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
Tammy L. Washburn Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 24, 2011 52 War or Dates
F,. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury j Street Address 25 Gregwood Circle
tit
p Manner of Death n Natural Cause l I Accident I I Homicide Suicide Undetermined Pending
iliCircumstances ' Investigation
,Las Medical Certifier Name Title
0 Paul Bachman,MD
Address
Warrensburg Health Center,Warrensburg,NY
Death Certificate Filed District Number RegA to Number
City, Town or Village Queensbury c(A n I
❑Burial Date , Cemetery or Crematory
❑Entombment December 28, 2011 Pine View Cemetery
Address
ID Cremation Quaker Road, Queensbury, NY 12804
Date ' Place Removed
Z Removal and/or Held
O and/or Address
H Hold
0 Date Point of
11.
N Transportation Shipment
p by Common Destination
Carrier
(Disinterment Date i Cemetery Address
( I Reinterment Date Cemetery Address
1
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home _ 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
h- Remains are Shipped, If Other than Above _
2 Address
CC
W
13.
Permission is hereby granted to dispose of the human remains described ove as indicated.
* Sc _ (
Date Issued � '2-7 (c)01(Registrar of Vital Statistics , t �
(signature)
District Number 519 S Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition rAN3, los7 Place of Disposition " nt 0u0 C 4i f nvc
Ili (address)
(I)
re (section) 7 (lot numb (grave number)
Q Name of Sexton or Person in Charge Premises ( cr)+ P_ f.uit
W 4 (please print)
Signature _ Title CQylTOiL
(over)
DOH-1555(02/2004)