Washburn, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH 41 ( 13
Vital Records Section 1Burial - Transit Permit
Name First Middle Last Sex
Kenneth L. Washburn Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 23, 2012 68 War or Dates
IPlace of Death Hospital, Institution or
L!J City, Town or Village Kingsbury Street Address 3014 Route 4
Manner of Death Natural Cause ❑ Accident C0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Jennifer Stratton, MD
Address
14 Manor Drive QueF.insbury, NY 12804
Death Certificate Filed District Number Register Number
n
City, n Village ` 14.E - �hJ�
❑Burial Date Cemetery or Crematory
February 27, 2012 Pine View Crematorium
❑Entombment Address
IKICremation Quaker Road Queensbury,Nlt 12804
Date Place Removed
❑ Removal and/or Held
{ ; and/or Address
E Hold _
to Date '. --+ -Point of
eL ❑Transportation Shipment
by Common Destination
CI Carrier
❑ Disinterment Date f Cemetery Address
i
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
IX
1.1.1 __
ls.; Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued .2/7 y/a-6-/� Registrar of Vital Statistics � Nt 1��.�t—
(signature)
District Number „1'74,�— Place , -urz ) 1 /) j
e
1-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition „arcl jtwit Place of Disposition .c;;,),�V,la C ►eior
2 (address)
W4:0-
ft (section) (lot number)C (grave number)
Name of Sexton or Per n in Charge Premises llfu1 r 0+u14-
(please print)
Signature if Title CQCtw►l4iDR
(over)
DOH-1555 (02/2004)