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Ball, Vernon NEW YORK STATE DEPARTMENT OF HEALTH f . tt I Z2 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Male Vernon F Ball Date of Death Age i If Veteran of U.S. Armed Forces, 2/26/2012 92 i War or Dates WWII Place of Death I Hospital, Institution or ig `w Town 0W Lake Luzerne 1 Street Address 125 Ralph Rd. Manner of Death iij Ix!Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title t'1 William Tedesco MD ,.. , Address Glens Falls,NY Death Certificate Filed 1 District Number Register Number ¢K Town 0 tl'='it Lake Luzerne i 5656 - Date Cemetery or Crematory ❑Burial 3/2/2012 Pine View Crematory Address ©Cremations Queensbury,NY 12804 . Date Place Removed Removal i and/or Held n. and/or Address Hold O ; Date Point of N❑Transportation I Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment• Date Cemetery Address Permit Issued to Registration Number <'. Name of Funeral Home Brewer Funeral Home, Inc, 00211 Address 24 Church St., Lake Luzerne,NY 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped. If Other than Above Address 4 Permission is hereby granted to dispose of the human ains de cribed a o e as indica . Date Issued ,2/Z, 020/2Registrar of Vital Statistics / / ', (s nature) District Number3�S Place Z 51,2.--x,..f--- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i- WDate of Disposition 114,E (.r IOi2. Place of Disposition R,uUtev CWifOr•- 2 (address) W tO C (section) ` lot number)c (grave number) Name of Sexton or Pers in Charge Premises (. �r'i% r —44411- Z Ll (please print) LU Signature I J c� Title ce-EA }}.-d(t. DOH-1555 (10/89) p. 1 of 2 VS-61