Washburn, Dorothy V .tr 116
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dorothy V.Washburn Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/28/2023 90 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 8 Grover Avenue,Moreau Town,New York 12803
,p Manner of Death ❑X Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 6
Burial Date Cemetery,Crematory or Facility Name
02/01/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
0❑Removal Date Place Removed
and/or and/or Held
~
N Hold Address
0
t3. Date Point of
to❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Otherthan Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/01/2023 Registrar of Vital Statistics Leeann McCabe(ECectronica(Ty Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�/ ?
Z Date of Disposition 2/3 Z 3 Place of Disposition -P„t V� /�7��+
W (address)
W
N CC (section) �l (ice number/<= `.,t (grave number)
/tl
8 Name of Sexton or Person in Charge of Premises '
tt
ase print)
W Toe
Signature C/� Title �� �
DOH-1555(07/18)p 1 of 2
1. 6 3 5 Q
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#