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Ballentine, Delia NEW YORK STATE DEPARTMENT OF HEALTH " 1 Burial - TranS���ermit Vital Records Section Name First Middle Last Sex Delia Pauline Ballentine Female Date of Death Age If Veteran of U.S. Armed Forces, March 8, 2011 80 War or Dates Place of Death Hospital, Institution or City, Town or Village Saratoga Springs Street Address WESLEY HEALTH CARE CENTER, INC Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Richard Teetz, M.D. Dr. Address Cambridge Family Health Center Cambridge, NY 12816 Death Certificate Filed District Number 'T`�U� Register Number City, Town or Village /43 s❑Burial Date Cemetery or Crematory March 14, 2011 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ti ❑ Removal and/or Held and/or'rye=° Hold Address Date Point of ❑Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address �; Date Cemetery Address ' ❑ Reinterment xRE Permit Issued to Registration Number �. Name of Funeral Home Carleton Funeral Home, Inc. 00276 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human rem ' cr' ed a indicat . ,, Date Issued 3/9,60// Registrar of Vital Statistics (signature) District Number 7L5V/ Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,i * Date of Disposition 3-(1-tt Place of Disposition 9,ni V liw d"cfor,u.._ (address) , (section) j} (lot num r) (grave number) Name of Sexton or rson in Chary- of Premises ////,�(+ra .1 { (please print) Signature 9 Title CRC Ai phi (over) DOH-1555 (02/2004)