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Ball, Bruce NEW YORK STATE DEPARTMENT OF HEALTfi " Vital Records Section Burial - Transit Permit Name First Middle Last Sex Bruce Ball Male • Date of Death Age If Veteran of U.S. Armed Forces, November 9, 2017 69 War or Dates Place of Death Hospital, Institution or City, Town or Village Moreau Street Address 16 Terry Drive • Manner of DeathL.Li Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Ageel A. Gillani, M.D. Dr. Address 102 Park Street Glens Falls, NY 12801 LAi Death Certificate Filed District Number Register Number City, Town or Village Moreau 4./5(O2 . 0 ❑Burial Date Cemetery or Crematory November 13, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination T. Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address • Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 r A• ddress 136 Main Street, South Glens Falls NY 12803 ' N• ame of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 4 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ,///31(7 Registrar of Vital Statistics /f1 ‘1"`— (signature) District Number 4 ccop.- Place 35/ Ay�Ld3 / ..,l m_cfec ZG4 . Ny certify that the remains of the decedent identified above were disposed of in accordance with this permit on: to Date of Disposition 11/13/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) A (lot number) (` (grave number) 0 Name of Sexton or Person in Charge of remises C�t i \._ Sv.r 1 2- (jease print) W. Signature (_A Title 6 "M 4-- (over) DOH-1555 (02/2004)