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Washburn, Cheryl Ann 4-c,6 NEW YORK STATE DEPARTMENT OF HEALTHr , Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Cheryl Ann Washburn Female Date of Death Age If Veteran of U.S.Armed Forces, 07/22/2021 76 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital WW Manner of Death © Natural Cause El Accident Homicide El Suicide El Undetermined n Pending V Circumstances Investigation Q Medical Certifier Name Title Christopher Hoy MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 312 ▪Burial Date Cemetery,Crematory or Facility Name 07/28/2021 Pine View Crematory Entombment Address lCremation Queensbury Town,New York ▪Donation gRemoval Date Place Removed and/or and/or Held F. Hold Address 0 a- Date Point of (.0 ❑Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom l• Remains are Shipped,If Other than Above ,g Address W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/28/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Il- W Date of Disposition -i l Place of Disposition pi„,, vi uA, Grtr,yi r,! 2 (address/ W CC N (section) (lot number/ (grave number/ • Name of Sexton or Person in Charge of Premises �ti(r„ty S Et/if<5 Z (please print) W Signatures / Title `/re"ctior DOH-1555(07/18)p l of 2 Public Health Law Sec. 4145(2b) 014964 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#