Washburn, John NEW YORK STATE DEPARTMENT OF HEALTH. /03
Vital Records Section Burial Transit Permit
ti Name First Middle Last Sex
John Urban Washburn Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 16, 2015 81 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Bernardo R Villajuan, Dr.
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District � rr Regi ter,IVumber
City, Town or Village Fort Edward
❑Burial Date Cemetery or Crematory
:• February 17, 2015 Pine View Crematory
04❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
' xF and/or Address
Hold
Date Point of
. ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ins descri ed a ovated.
Registrar of Vital Statistics YY
4 Date Issued )I7/15 f d----
7 (signature)
- District Number 6965 Place J�YV -6 L dWa 4
~ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/17/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number)c (grave number)
Gh
Name of Sexton or Person in Charge of Premises is Jam`
(please print)
. � Title Signature � akv1tg1 t'—
(over)
DOH-1555 (02/2004)