Ball, Claudia . . ., A- 7 c(
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Claudia R. Ball Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 11,2012 80 War or Dates
H Place of Death Hospital, Institutiorlirondack Tri-County Health Care
iZ City, Town or Village Johnsburg I Street Address Center
Manner of Death I XI Natural Cause I I Accident Homicide I I Suicide Undetermined Pending
LU Circumstances Investigation
uw Medical Certifier Name Title
G Dean Reali
Address
North Creek Health Center,North Creek,NY 12853
Death Certificate Filed ; District Number Register Number
City, Town or Village Johnsburg 5655 al
❑Burial Date Cemetery or Crematory
El Entombment January 12,2012 Pine View Crematory
Address
Ei Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 1 Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address
tY
la
a
Permission is hereby granted to dispose of the human r 'ns describede^�� abov as indicated.
Date Issued I-• ti'ao,a Registrar of Vital Statistics L._1 (0 C,1A,C�.�
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were dispose f in accordance with this permit on:
I—
Z
w Date of Disposition 1/1-I/►o Place of Disposition tit Vrty f. 4urf,r...
(address)
W
re (section) I (tot number) (-' (grave number)
pName of Sexton or Perso .n Charge of P mises Cty� 1.F— )CP
Z i (please print)
W
Signature .,� Title EYh4 60^e
(over)
DOH-1555 (02/2004)