Washburn, Sandra Lee IF 4 2-7‘0
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Sandra Lee Washburn Female
' Date of Death Age If Veteran of U.S.Armed Forces,
i 03/25/2022 78 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death Natural Cause Accident Homicide Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Eric Santell NP
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 31
nBurial Date Cemetery,Crematory or Facility Name
03/29/2022 Pine View Crematory
❑Entombment Address
F JCremation Queensbury Town,New York
,--1 0Donation
a❑Removal Date Place Removed
and/or and/or Held
N
Hold Address
d. Date Point of
CO❑Transportation
CI Common Shipment
Carrier Destination
O
Disinterment
9 Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
1`�ii Remains are Shipped,If Other than Above
Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/28/2022 Registrar of Vital Statistics .Aimee L Mahoney(ECectronica1CySigned)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3130 in_ Place of Disposition �ntlL. r d P3�
a (address)
41
(section) _(lot number) (grave number)
0`. Name of Sexton or Person in Char o Premises dn, asL.-
print)
� l't
Z /P(° �y�
, Signature Title �`�""'t�C�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#