Washburn, Linda NEW YORK STATE DEPARTMENT OF HEALTH e 6, t
Vital Records Section Burial - T ansit Permit
'.1 Name First Middle Last Sex
Linda Lee Washburn Female
, Date of Death Age If Veteran of U.S. Armed Forces,
January 24, 2014 50 War or Dates
Place of Death Hospital, Institution or
j City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Deathrrl Xi Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 1-1 Undetermined ri"—I Pending
CircumstancesInvestigation
Medical Certifier Name Title
Eric Pillemer, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number �j � Regist umber
4,1 City, Town or Village Glens Falls au)
`
❑Burial Date Cemetery or Crematory
January 29, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
ti and/or Address
Hold
- Date Point of
Transportation Shipment
by Common Destination
1=` Carrier
iza
w: ❑ Disinterment
Date Cemetery Address
li "❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 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
,,H
Permission is hereby ranted to dispose of the human remains descr' a ov s in d.
Date Issued D/ Z$2CY Registrar of Vital Statistics � > •
_ (signature)
District Number &2/ Place j� i & ti>f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,- Date of Disposition 01/29/2014 Place of Disposition Quaker Road Queensbury,NY 12804
= (address)
,
c (section) j 4 (lot number).— (grave number)
Name of Sexton or Person • Charge of Premises
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please print)
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Signature 42— Title Ciz T(12
(over)
DOH-1555 (02/2004)