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Washburn, Barry NEW YORK STATE DEPARTMENT i ' HI AL7�1 I S I Vital Records Section Burial - Transit Permit ,,. Name First Middle Last • Sex Barry D Washburn male ;` Date of Death Age If Veteran of U.S. Armed Forces, 3-15-2011 61 War or Dates 0 14 Place of Death Hospital, Institution or Lake 7 5 �i e s k a u S t Geor e City, Town or Villageg Street Address W.0 Manner of Death g Natural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending Mt Circumstances Investigation U. ui Medical Certifier Name Title 0 William Orluk Coroner Address Chestertown, NY aii Death Certificate Filed District Number Register Number City, Town or Village Lake George 5�j Q ❑Burial Date Cemetery or Crematory 03-18-2011 Pine View Crematory s 0 Entombment Address im©Cremation Quaker Rd . Queensb.ury , NY Date Place Removed ,' ❑Removal and/or Held and/Holdor Address it Date Point of fiID Transportation Shipment a by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Stafford Funeral Home Regi8ttatioR Number Name of Funeral Home Address 90 Montcalm St Lake George NY Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above Address i t: fl' Permission is hereby granted to dispose of the human rema ns described above as indicateedd iiiiia Date Issued 03 / /2G// Registrar of Vital Statistics '(� S(;L4.7 ( (signature) District Number 5 6 2 0 Place Lo k 61-ear -) /.Pu /or 9 <: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 141 Date of Disposition 3_ .t 1 Place of Disposition Pnivit,9 6 .41J f,v4.- (address) COta CC (section) • (lot r ?fiber) (grave number) Name of Sexton or Person in Ch ge of Premises r%1 e hvit (please print) Signature G "� Title C 'h Mite, (over) DOH-1555 (02/2004)