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Ballou, Ferne t NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit io Name First Middle Last Sex Ferne Ballou Female Date of Death Age If Veteran of U.S. Armed Forces, 02 / 07 / 2016 92 War or Dates N/A 14 Place of Death Hospital, Institution or ZCity, Town or Village Greenfield Street Address 302 Ballou Road p Manner of Death®Natural Cause [�Accident ❑Homicide 0 Suicide Undetermined ri❑Pending Circumstances Investigation W Medical Certifier Name Title O Jama Peacock MD Address 510 Geyser Rd Ballston Spa, NY 12020 di Death Certificate Filed District Number Register Number aCity,Town or Village Greenfield c� 7 Lf 11®Burial DateCemetery or Crematory /O / JO/‘ :?:`, Entombment Pine View Crematory Address ©Cremation Queensbury, NY ;.:."<, Date Place Removed Z❑Removal and/or Held and/or Address tit Hold CA 0 Date Point of Q Transportation Shipment 5 by Common Destination Carrier '< Disinterment Date Cemetery Address Eiri Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Compassionate Funeral Care, Inc 00364 < Address liE 402 Maple Ave., Saratoga Springs, NY 12866 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address ir ICI .- 2 "` Permission is ereby granted to dispose of the human re s descrOl abov s' icated. iiiig Date Issued ,6 ®, �tc,Registrar of Vital Statistics (signature) District Number vs-s--7 Place Greenfield , New York ▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Iii Date of Disposition -10-(6 Place of Disposition p nc, v,emi cr-tim-Id,y (address) 1i 0 CC (section) (lot number) (grave number) O Name of Sexton o.r Person ip Charge of Premises •. dctmt y. Se0,1 f c;2 (please print) • tE Signature ,/ ' Title C c�mc-lo • (over) DOH-1555 (02/2004)