Ball, William NEW YORn STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First � Midge Last, Sex
�-
,Ga. ��r-t. 2jf2
Date of Death Age If Veteran of U.S. Armed Forces,
;,/i S /1/ 7 War or Dates al-'
1: Place of Death L7.��-�e s, Hospital, Institu n or
ILICity, Town or Villages _,�_ Y Street Address � �% cfre--,:e454-
aManner of Death Natural Cause Accident D Homicide Suicide Undetermined Pending
LUCircumstances Investigation
lit Medical Certifier Na r Title
0 m, % - ,� ?I)
Address , ��`
>.-1" fif, g,,,,,,,,,„„4„...„ .
:.,:. ..: Death Certificate Filed District Number Register Number
City, Town or Village 67,4€1. -1-4-4.-.e---7 `> / /
Mauna! Date Cemetery o Crema ory
} , _
❑Entombment Address r � � � r
❑Cremation ..f..'.. a rf-1-'
Date Place/Removed
Removal and/or Held
C ❑and/or Address
i,- Hold
VI
0 Date Point of
Q Transportation Shipment
et by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 727,, ti= ,7�' LAddress37-1 4;7-4,-,A--Z-c gi 4),„&e.,A1-1.-Liee,—.1
Name of Funeral Firm Making Disposition or to Whom 1
104 Remains are Shipped, If Other than Above
Address
111
d' Permission is hereby granted to dispose of the human re ains described above s indicated,
Date Issued ��y I/ Registrar of Vital Statistics ,�,LX-1,..-.
(signature)
District Number S_t Place /.
-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
1.11 Date of Disposition 2 . 21 . 11 Place of Disposition Pine View Cemetery
2
Ui
(address)
f4 Mohican 32 C 1
IX (section) (lot number) (grave number)
0 Name of Sexton or Persgp in Charge of Premises Michael Gen ier
%t 1 (please print)
Signature /�f" Title Superintendent
(over)
DOH-1555 (02/2004)