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Ballard, Clayton -HL) NEW YORK STATE DEPARTMENT, OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Clayton Wilford Ballard Male Date of Death Age If Veteran of U.S. Armed Forces, December 27, 2016 90 War or Dates t Place of Death Hospital, Institution or ram; City, Town or Village Hudson Falls Street Address 143 John Street Manner of Death .i Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined El 1---I Pending CircumstancesInvestigation Medical Certifier Name Title John E. Lukaszewicz, Dr. Address 84 Broad Street Glens Falls, NY 12801 Death Certificate Filed District Num,per Register Number City, Town or Village Hudson Falls -3 7a, - - (ffG ❑Burial Date Cemetery or Crematory I Z.- I Za \ R(o Pine View Crematory '❑Entombment Address "'_= ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held a and/or Address p Hold CA Date Point of W ❑Transportation Shipment ; by Common Destination Carrier Date Cemetery Address El Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 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 ' s described above as indicated. Date Issued /a-d9 Registrar of Vital Statistics. a t (signature) District Number Place ,��,.` a Q9 n 6. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I2 Z�/J(� Place of Disposition Quaker Road Queensbury,NY 12804 ThieU (,i r�f./C�-i0+.i� / / ,� f (address) lit CO CC (section) J >t number) (grave number) Name of Sexton or Charge of Premises 9°` ft 0,✓l G j'j2zse.--ke (please print) Signature Title C/'en se. - (over) • DOH-1555 (02/2004)