Washburn, Aussie • - Si -It (P CO
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Aussie Washburn , Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 19,2013 79 War or Dates
Place of Death Hospital,Institution or
IZ City, Town or Village Johnsburg Street Address 2404 State Route 8
Manner of Death :��Natural Cause ( !Accident fl Homicide Suicide Undetermined Pending
tU Circumstances Investigation
W Medical Certifier Name Title
0 Paul Bachman
Address
BHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register NurAber
City, Town or Village Johnsburg 5655 3 /
❑Burial Date Cemetery or Crematory
Entombment November 20,2013 Pine View Crematory
Cil Address
El Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z ( (Removal and/or Held
9. and/or Address
F' Hold
V)
p Date Point of
u) ( (Transportation Shipment
p by Common Destination
Carrier
I Disinterment Date Cemetery Address
( (Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
2 Address
CC
W
tL Permission is hereby granted to dispose of the human, ains describ above as in icated.
Date Issued 11- au. c_L,)13,Registrar of Vital Statistic °
(signatur
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance" with this permit on:
W Date of Disposition 11-1 i' /
.1-13 Place of Disposition >a £ 4,cs
2 (address)
w
Ce
O (section) X (lot number)(" (grave number)
p Name of Sexton or Person 'n Charg of Premises i,r
Z ( /ease print)
ui
Signature
Title CV;M4-P-o+t.
(over)
DOH-1555 (02/2004)