Ball, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Robert W. Ball Middle Last Sex
Male
Date of Death 5-2 0-2 01 3 Age 7 7 If Veteran of U.S. Armed Forces,
War or Dates NO
Place of Death City of GLens Falls Hospital, Institution or Glens Falls Hospital
City, Town or Village Street Address
Manner of Death® Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Graham Atkins MD
Address
161 Carey Road Queesbury, NY 128(l4
Death Certificate Filed District Number Register,Nu_mber
City, Town or Village City of GLens Falls
❑Burial Date Cemetery or Crematory
May 21 , 2013 Pine view Crema.trry
❑Entombment Address
['Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to MB. Kilmer Funeral Home Registration08 Number
Name of Funeral Home 01 078
Address
136 Main St. South Glens Falls, New York
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is here y ranted to dispose of the human remains,rito aWy a d.
i.3
Date Issued Q 1/ Registrar of Vital Statistics �(
// (signature)
District Number JGO/ Place 6pl�hb `lS, /v7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition SZZ't 3 Place of Disposition P 1 N t- V( /rrv) Cie"O9 - 7
(address)
(section) lot number) (grave number)
Name of Sexto •i e Charge of Premises
(plea► _/ C S - 4sSignature - C �'y Title
(over)
DOH-1555 (02/2004)