Ball, Pauline NEW YORK STATE DEPARTMENT OF HEALTH ' f"E nµ r
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Pauline Marian Ball Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 3, 2013 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley
• Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined I--' Pending
CircumstancesInvestigation
', Medical Certifier Name Title
Address
Death Certificate Filed District Number Register umber
- City, Town or Village Argyle J� 50
El Burial Date Cemetery or Crematory
, ❑Entombment Pine View Crematory
Address
g_®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
• and/or Address
Hold
Date Point of
6
❑Transportation Shipment
by Common Destination
• Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the hum ains de c ibed" bove a i i ated.
L\13 Registrar of Vital
Date Issued Statistics ),\ �'\ 1 �--
L
(signature)
District Number --\c I Place \r\-- U\l \ ..JJ
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t Date of Disposition i1-1013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) 4 (lot numb (grave number)
4.
la Name of Sexton or Perso in Charge f Premises t sa --- -iti
I (please print)
Signature Title c 26 e
(over)
DOH-1555 (02/2004)