Washburn, Kenneth •
NEW YORK STATE DEPARTMENT OF HEALTH / -it
Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth F. Washburn Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 18,2015 61 War or Dates
r= Place of Death Hospital, Institution or
Z= City, Town or Village C/O Glens Falls Street Address Glens Falls Hospital
W Manner
of Death ' Natural Cause Accident I I Homicide Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
Suzanne Bergin MD
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number tr� // Register Number
City, Town or Village J bo i 5 I Z
❑Burial Date Cemetery or Crematory
❑Entombment October 20,2015 Pine View Crematory
Address
❑X Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed ------
ZZ Removal and/or Held
and/or Address
H Hold
U
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to — 1 Registration Number
Name of Funeral Home Alexander-Baker Funeral Home I 00037
Address
3809 Main Street,Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
te
W°
O° Permission is hereby granted to dispose of the human remains described above as indicated.
'. Date Issued 10/20/2015 Registrar of Vital Statistics L.' J'J Q. L am^ *
(signature)
District Number 5601 Place C/O Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �++
iii Date of Disposition 1o/Zi '1S Place of Disposition fut.III;,,./ Crttnql0n
W (address)
co
C (section) /� (lot number (grave number)
pName of Sexton or Person in Charge of Premises 1/Ijn,( ,, 3s viatj—
Z (please print)
W
Signature Title (r+ttOft
(over)
DOH-1555 (02/2004)