Washburn, William x -F7IL7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
WILLIAM WASHBURN MALE
Date of Death Age If Veteran of U.S.Armed Forces,
08/27/2015 62 War or Dates NO
!- Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER HOSPITAL
0 Manner of Death Natural Undetermined Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
Wj Medical Certifier Name Title
p, NATARAJAN RAVE MD
k;' Address
43 NEW SCOTLAND AVE. ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1825
Date Cemetery or Crematory
❑ Burial 08/31/2015 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
I— Hold
CO
0 Date Point of
tL Transportation Shipment
CO ❑ By Common Destination
p Carrier
El Disinterment
Cemetery Address
Disinterment
ElDate Cemetery Address
Renterment
Permit Issued To Registration Number
Name of Funeral Home M. B. KILMER FUNERAL HOME 01079
Address
82 BROADWAY, FORT EDWARD, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Cd
Ili'
a Permission is hereby granted to dispose of the human remains described above as indicated.
" Date 08/28/2015 Registrar of Vital Statistics �2't^-'�.e , 'o�
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6— Date of Disposition 91ill s Place of Disposition Pieta_ G f4"44r•-•1
I' (address)
wCO
0 (section) (lot number) (grave number)
0 ('
W' Name of Sexton or Person in Charge of Premises t, J e►u►46r
(please print)
Signature , Title 4 .
(over)
DOH-1555 (02/2004)