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Hickey, Martha NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle -Last Sex Martha A Hickey Female Date of Death Age If Veteran of U.S.Armed Forces, April 17,2017 73 War or Dates Place of Death Hospital, Institution or City, Town r Villas Ballston Spa Street Address Saratoga Center Manner of Derma h©Natural Cause 0 Accident 0 Homicide El Suicide riUndetermined El Pending Circumstances Investigation Eft Medical Certifier Name Title rit Vina Patel MD Address 149 Ballston Ave Ballston Spa, NY 12020 Death CertificatePiled Ballston S a District Number Register Number 74, City, Town or illa p 4520 18 ❑Burial Date Cemetery or Crematory April 18,2017 Pineview Crematory OF El Entombment Address ®Cremation Queensbury, NY Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination IT Carrier 40 Disinterment Date Cemetery Address 4 Reinterment Date Cemetery I Permit Issued to Registration Number Name of Funeral Home Densmore Funeral He 00448 Address 7 Sherman Ave Corinth, NY 12822 fe Name of Funeral Firm Making Disposition or to Whom 11 Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains describ d ov as indicated. Date Issued April 18, 2017 Registrar of Vital Statistics Z - /(/1,_.__ (signature) District Number 4520 Place Village of BallstonSpa certify that the remains of the decedent identified above were disposed of in accordance with this permit on: lw Date of Disposition 1/7 Place of Disposition Pi?7Q.L), ('C 24,k, f (address) / so ''' r (section) l (lot nu er) / (grave number) AT Name of Sexton or ers in Charge of Premises � wlra✓t 04 I'�C�C. t � FT 1 (please print) To Signature Title Gcle-` cv o r (over) DOH-1555(02/2004)