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Ballard, Gladys NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit F�ermit Vital Records Section Name First Middle Last Sex Gladys H Ballard Female Date of Death Age If Veteran of-U.S.Armed Forces, 1. July 1, 2011 76 War orDtttes Z Place of Death Hospital,Institution or City,Town,or Village Ticonderoga Street Address Moses-Ludington Hospital 0 Manner of Death Natural Cause 0 Accident 0 Homicide 0Suicide 0 Undetermined 0 Pending W Circumstances Investigation O Medical Certifier r Name Title W l v c/c'e c,-J'7©' Al D 0 Address ai/e/c-P/z S7Rsec-e/ //,'c 'c avzc; `7i Death Certificate Filed District Number 0 Register Nu ber City,Town or Village Ticonderoga / f V a IP ❑Burial Date Cemetery or Crematory July 5, 2011 Pineview Crematorium ❑Entombment-Address ii Q Cremation Town of Queensbury Queensbury, NY 12804 Date Place Removed 0 0 Removal and/or Held 7. and/or Address I' Hold N Date Point of 0 0 Transportation Shipment d by Common Destination Carrier Date Cemetery Address 6 0 Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Jillson Funeral Home, Inc. 00885 Address 46 Williams Street, Whitehall, New York 12887 1- Name of Funeral Firm Making Disposition or to Whom et Remains are Shipped, If Other than Above W Address CI. Permission is hereby granted to dispose of the human remai cribed abo/ as i ed. Date Issued 7 /a 6/1 Registrar of Vital Statistics (signature par? District Number / /4 Place Ticonderoga,New rk I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 07/05/2011 Place of Disposition Pineview Crematorium 2 (address) W N 0 (section) , (lot numbe (grave number) O Name of Sexton or Perso ' Charge of emises (hti 5} r vlaff Z (1 please print) W Signature 4ia Title CQc r roQ. (over) DOH-1555 (02/2004)