Washburn, Mark J �F 1 s io
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle
Mark J.Washburn Last Sex
Date of Death Male
I Age If Veteran of U.S.Armed Forces,
07/14/2022 58 Years
War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls
liJ Street Address Glens Falls Hospital
0 Manner of Death Natural Cause ❑Accident W Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name
Title
Marcille Labban MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number
City,Town or Village Register Number
5601 368
Burial Date Cemetery,Crematory or Facility Name
07/18/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
c❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a. Date Point of
CO❑Transportation
IS by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped,If Otherthan Above
2 Address
CC
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/18/2022 Registrar of Vital Statistics Megan Noun(ECectronica1Ty Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition l)ZI)12 Place of Disposition
(address(
W
(section) c- (lot number) (grave number)
8 Name of Sexton or Person in Charge o mises ��► �, St.,,
ZI (please print)
• Signature Title tCAll ro
DOH-1555(o7/i8)p t of 2
1 0
Public Health Law Sec. 4145(2b)
Receipt
Human remains of =r delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#