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Washburn, Sean Scott NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Sean Scott Washburn Male Date of Death Age If Veteran of U.S.Armed Forces, 10/23/2021 49 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 6 Smoke Ridge Rd,Queensbury Town, New York 12804 IIJ Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title C1 Paul Bachman MD Address 9 Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 210 Burial Date Cemetery,Crematory or Facility Name 10/26/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation ElRemoval Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of N ❑Transportation by Common Shipment Carrier Destination Date Cemetery Address Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/26/2021 Registrar of Vital Statistics Caroline Jfi&fegartfe Barber(E1 ctronicalfy Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 10)11 114 Place of Disposition f9Z 111—. t►--I W 2 (address) W CC N (section) / (lot number) (grave number) ff0 Name of Sexton or Person in Charge of Prerr� es 6f�1!,� ` &AA t� Z (pleas print) / W Signature L:� Title l�Y 'N+b{jUy2 DOH-1555(07/18)p 1 of 2 • Public Health Law Sec. 4145(2b) Receipt Human remains of t ' '� delivered on ' , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 1 / f .'