Ballard, Anne NEW YORK STATE DEPARTMENT OF HEALTH
# 44
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anne M. Cordato Ballard Female
Date of Death Age If Veteran of U.S. Armed Forces,
Jan. 21 , 2017 82 yrs. War or Dates no
14 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Uj
Manner of Death 0 Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
11 Circumstances Investigation
tig Medical Certifier Name Title
Marvin Davidowitz MD.
Address
iNi 100 Park St. , Glens Falls, NY. 12'101
PliiN Death Certificate Filed District Number Register Number/^
City, Town or Village Glens Falls 3 60\
❑Burial Date Cemetery or Crematory
,Tan. 23, 2.017 PineVi.P.M Crematorium
❑Entombment Address
liiiiiiii Cremation ')u7tker '-20. , flueensbury, NY. 12904
Date Place Removed
❑Removal and/or Held
lei and/or
M;; Address
Hold
0 Date Point of
Transportation Shipment
CS by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
ii Permit Issued to Mason Funeral Home �ieiglisltrftion Number
Name of Funeral Home
'' Address P.O. Box 277
18 George St. , Fort Ann, NY. 12827
iiiiiiiiiii Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
IX
1U
fl` Permission is hereby granted to dispose of the human remains described above as indicated.
ini
Date Issued Jan.2 3, 2 01 F7egistrar of Vital Statistics (,
(s nature)
Iiiiiiii District Number 5 b0► Place G S -EA , k S,t y 1 2804
,_.>;_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill• Date of Disposition f/23in Place of Disposition 7.0.10sr,.,/ 4,niettorpa
(address)
iii
tel
CC (section) lot number) (grave number)
0
a Name of Sexton or Person in Char a of Premises A,r, Sta9(f+
.*.►... (ple print)
44 Si nature IL Title f vATD&
g
(over)
DOH-1555 (02/2004)