Ball, Mary 5(/'
NEW YORK STATE DEPARTMENT OF HEALTH r D
Vital Records Section Burial Transit Permit
AW
iiN Name First Middle Last Sex
Mary R . _ Ball Female
iiiiiiiiil Date of Death Age If Veteran of U.S. Armed Forces,
3/6/2005 91 War or Dates No
`.,..- Place of Death Hospital, Institution or
'.,.,,��" City, Tent xcir lingli Glens Falls Street Address Glens Falls Hospital
UManner of Death Natural Cause Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0 T.T. Sirldinni M D
Address
Glens Falls . NY
€: Death Certificate Filed District Number Register Number
gg City, ' iI e rTlP„G FallG cFnl l '3h
Date Cemetery or Crematory
❑Burial 3/7/2005 Pine View Crematory
Address
QCremation Queensbury, NY
Date Place Removed
Z Removal and/or Held,
and/or Address
g Hold
Date Point of
ei❑Transportation Shipment
3 by Common Destination
Carrier
::: Disinterment Date Cemetery Address
::::: Reinterment Date Cemetery Address
:: Permit Issued to Registration Number
iiiiiiii Name of Funeral Home Brewer Funeral Home , Inc . 00212
iiiiil Address
24 Church St . , Lake Luzerne , NY 12846
J. Name of Funeral Firm Making Disposition or to Whom
Re Remains are Shipped, If Other than Above
Address
W
giiii Permission is hereby granted to dispose of the human remains desccrr e abb ye s ind- ted
Date Issued X f) -7 .0_) Registrar of Vital Statistics
(signature) / f
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:
F
W Date of Disposition 3 ii 05- Place of Disposition P i*E4 c- V 1=t,L) Gt2.>~N+✓k 3re.m. ..0,^/\,
2 (address)
U.I
cc (section) (lot number) (grave number)
2 Name of Sexton or Person in Charge of Premises G a►c '-( C 2n iv-r
g (please print)
W SignatureG [ Title Ca AA✓h-I-00—
(over)
DOH-1555 (9/98)
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