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Washburn, Gerald W. Sr. / sg NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gerald W.Washburn Sr Male Date of Death Age If Veteran of U.S.Armed Forces, 02/12/2023 86 Years War or Dates 1954-1958 Place of Death Hospital,Institution or W City,Town or Village Hartford Town Street Address 3499 State Route 196, Hartford Town, New York 12827 p Manner of Death El Natural Cause ❑Accident Homicide Duicide Undetermined ❑Pending W Circumstances Investigation 0 Medical Certifier Name Title Melanie Duerr NP Address 47 Tom Phelps Lane,Mineville Hamlet,New York 12996 Death Certificate Filed Town Of Hartford District Number Register Number City,Town or Village 5759 2 Burial Date Cemetery,Crematory or Facility Name 02/14/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York DDonation ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of (I)ETransportation 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 I— Remains are Shipped,If Other than Above Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/14/2023 Registrar of Vital Statistics Denise Petteys(E(ectronical(y Signed) (signature) District Number 5759 Place Town Of Hartford I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H , 9 W Date of Disposition -2_/.y^.zp j3 Place of Disposition e V j Cif seiv (address)_) W cc (section) (lo number) (grave number) GName of Sexton or Person in Charge of Premises f �.� �J(b Ci Z (please print) uJ Signature �'" � / Title Q��sry DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#