Ball, Wilfred 21
NEW YORK STATE DEPARTMENT OF HEALTH 61
Section . . , Burial - T �
Vital Records Seransit Permit
Name First Middle Last Sex
Wilfred Joseph Ball Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 11, 2015 58 War or Dates
I Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death X❑ Natural Cause Eli Accident ❑ Homicide ❑ Suicide Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
Ci Joseph C. Mihindu, MD,
Address
20 Murray Street Glens Falls, NY 12801
Death Certificate Filed District Number Register m er
City, Town or Village ,1-6a/
❑Burial Date Cemetery or Crematory
September 14, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
0 and/or Address
,. Hold
CO Date Point of
cO Transportation Shipment
U) by Common Destination
3 Carrier
riDisinterment Date Cemetery Address
EiReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
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
I— Remains are Shipped, If Other than Above
M Address
CC
W':
a" Permission is hereb granted to dispose of the human retrains d cribed ab ve as indh .ted.
Date Issued / Registrar of Vital Statistics 72_a�-) 0)`e
(signature)
District Number 560 / Place ..7L —,041 Je(S--�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 09/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2° (address)
W:
co
c (section) _ (lot numbe (grave number)
ca Name of Sexton or Person 'n Charge if Premises �r;+d�'�r,�+- (I.✓i'
Z I(please print)
W Signature 1 Mk Title /a�
(over)
DOH-1555 (02/2004)