Ball, Susan NEW YORK STATE DEPARTMENT OF HEALTH t L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
SUSAN J. BALL Female
` Date of Death Age If Veteran of U.S. Armed Forces,
November 9, 2011 72 War or Dates n/a
Place of Death Hospital, Institution or
Glens Falls, NY Glens Falls Hospital
City, Town or Village � Street Address
aManner of Death 7 Natural Cause 0 Accident El Homicide 0 Suicide Undetermined 0 Pending
1 - Circumstances Investigation
ta Medical Certifier Name Title
0 Christopher Hoy, MD
Address
Glens Falls, NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens falls, nil 5601
❑BUflal Date Cemetery or Crematory
Nov 14, 2011 Pine View Crematory
❑Entombment Address
laCremation Quaker Rd Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
F_- Hold
tl)
0 Date Point of
85 ❑Transportation Shipment
0 by Common Destination
Carrier
:Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
+ Address
53 Quaker Rd Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I` Remains are Shipped, If Other than Above
2 Address
w
P" Permission is hereby granted to dispose of the human remains described abo as indicat d.
Date Issued 11/11/11 Registrar of Vital Statistics eir—e—e-k-? . 0,)-C
(signature))
District Number Li / Place X;_-- 4.
,/
1 .
I certify that the remains of the decedent identified above were disposed of in accordance with this per ton:
Z.
iLI Date of Disposition uov ici Wit Place of Disposition Zht 41 Cirtnryivrtuti
(address)
In
ta
re (section) A (lot numb (grave number)
0
L Name of Sexton or Pers in Charge o Premises risk th,4f4
(please print)
PA Signature Title CQE 014-c
(over)
DOH-1555 (02/2004)