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Ball, Raelyn NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section E Name First Middle Last Sex RAELYN LEIGH BALL y FETAL Date of Death Age If Veteran of U.S.Armed Forces, 10/06/2013 FETAL War or Dates }-s Place of Death Hospital, Institution Z City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER © Manner of Deat Natural ❑ Undetermined ❑ Pending � ❑ Cause ❑ Accident ❑ Homicide Suicide Circumstances Investigation t) Medical Certifier Name Title iti o'. PETER COLE MD °'1 Address 43 NEW SCOTLAND AVE., ALBANY NY 12208 Death Certificate Filed District Number Register Number City,Town or Village City of Albany 101 FETAL Date Cemetery or Crematory ❑ Burial 10/09/2013 PINE VIEW CREMATORY ❑ Entombment Address ® Cremation QUEENSBURY, NY Date, Place Removed _ Z Z ❑ Removal and/or Held and/or Address Hold co d; Transportation Date Point of CO CI Common Shipment a Carrier Destination ❑ Disinterment Date Cemetery Address ❑ Date Cemetery Address Reinterrnent Permit Issued To Registration Number Name of Funeral Home M.B. KILMER F.H. 10178 Address 82 BROADWAY FORT EDWARD, NY 12828 Name of Funeral Firm Making Disposition or to Whom H-. Remains are Shipped, If Other than Above Address O Permission is hereby granted to dispose of the human remains des bed above as indi a ed. Date 10/07/2013 1IIssued Registrar of Vita! Statistics �`-� I ' � (signature) District Number 101 Place City of Albany, NY I certify that the remains of the decedent identified above were di posed of in accordance with this permit on: Z Date of Disposition Jt) f Place of Disposition i'ilk �L f� W (a dress) 2 to N re (section) (lot number) (grave number) 0 G �( 11 Name of Sexton or erson in C r of Premises S�j t1 .�/ C (please print) Signature 11 Title 01 ML / A.. (over) DOH-1555(02/2004)