Washburn, Harriet faNEW YORK STATE DEPARTMENT OF HEALTH a rl L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harriet Anne Washburn Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/24/2011 62 years War or Dates
f4, Place ot Death Hospital, Institution or
f City, Tow II-•- Street Address
ILI .V., XX Glens Falls Glens Fails Hospital
a Manner o eat ;�4 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
itt Circumstances Investigation
iii Medical Certifier Name Title
0
AddreMsatthew Anderson Attending Physician
17 Baywood Drive Queensbury, Ny 12804
Death Certificate Filed District Number Register Number
City, Towr r illt xX Glens Fails SAn1 146
al❑Burial Date Cemetery or Crematory
❑Entombment 03/29/2011 1 Pine view Cemetery
Address
Nig 54Cmation Qiieenshury, NY 12804 •
Date Place Removed
0, ❑Removal and/or Held
and/or
Hold Address
U)
0 Date Point of
05❑Transportation Shipment
a by Common Destination
gg Carrier
❑Disinterment Date Cemetery Address •
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
11 Lafayette Street Queensbury. N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
f
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Permission is hereby granted to dispose of the human remains descri a above as in• d.
iN Date Issued 03/29/2011 Registrar of Vital Statistics - ',
(signature)
District Number 5601 Place Glens Fails
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 �
lit Date of Disposition 3-3tO-,1 Place of Disposition fit�;1ittw Csew<tcri.
2 (address)
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U
C (section) ar;si-vpite, (lot n er) (grave number)
Name of Sexton or Person in Charge f Premises tit.,ut'
Z /�1 I (please print)
W. Signature L As/ Title (11kflwt d(
(over)
DOH-1555 (02/2004)