Ball, Randy L ,I....C. "
it 300
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Randy L Ball Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/03/2022 69 Years War or Dates
i_ Place of Death Hospital,Institution or
ILI
Z City,Town or Village Queensbury Town Street Address 380 Corinth Road,Queensbury Town,New York 12804
p Manner of Death III Natural Cause Accident 0 Homicide nSuicide Undetermined ❑Pending
W
U Circumstances Investigation
WC Medical Certifier Name Title
Adrianna Earl Other
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 66
Burial Date Cemetery,Crematory or Facility Name
04/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
f„ and/or and/or Held
N Hold Address
0
O. Date Point of
Cl)❑Transportation
G by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
EIReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/06/2022 Registrar of Vital Statistics Caroline?ftC1egarife Barber(ECectronicallySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— /_
Z /�Date of Disposition 7-7 ZOZZ Place of Disposition 7 Ne zfA
(address)
W
Q (section) (lot nu ter) (grave number)
Name of Sexton or Person in Cha of Pre #4(1197(J>>1, Web d
Z //1� / ease print)
l y
UJ Signature Title tl f-e_7rt. C---
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
'lfficial Funeral Directors Reg. or License#