Washburn, Dana NEW YORK STATE DEPARTMENT OF HEALTH
ti21
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dana Washburn Male
Date of Death Age If Veteran of U.S. Armed Forces,
▪ April 9, 2014 62 War or Dates
ge• Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
iii Manner of Death X Natural Cause Accident I ]Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
gi Joseph C.Minhindu MD
Address
20 Murray Street, Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
▪ City, Town or Village Glens Falls,NY 5601 II
❑Burial Date Cemetery or Crematory
❑Entombment April 14, 2014 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
051 1 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbur , NY 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
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gi
Permission is hereby granted to dispose of the human remains described abov a 'cated.
Date Issued `f i t I ( 1`i Registrar of Vital Statistics ,A6 " f2
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition till Il t Place of Disposition 44µ../ ( for 1 v•-•
W (address)
co
cc (section) (IL,-
(lot number (grave number)
Q Name of Sexton or Person in Charge of Premises 3st tit
Z
/11L ease print)
W
Signature . Title Coeim Ft
(over)
DOH-1555(02/2004)
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