Ladd, Judith B NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Judith B.Ladd Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/22/2023 84 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Fort Ann Town Street Address 196 Buttermilk Falls Road,Fort Ann Town,New York 12827
1a Manner of Death Natural Cause IllAccident ❑Homicide ESuicide Undetermined riPending
Circumstances Investigation
alMedical Certifier Name Title
Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 3
Burial Date Cemetery,Crematory or Facility Name
01/24/2023 Pineview Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
4 Removal Date Place Removed
and/or and/or Held
CA
Hold Address
CD Transportation Date Point of
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277, Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
f•. Remains are Shipped,If Other than Above
S Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/24/2023 Registrar of Vital Statistics Miranda Herringshaw(Electronically Signed)
(signature)
District Number 5754 Place Town Of Fort Ann
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F I �
Date of Disposition 1173 I73 Place of Disposition f'•4
(address)
UI
tr (section) (lot number) �1rv>� (grave number)
8 Name of Sexton or Person in Charge of Premises //!J1 L-
(prelise print)
Ui Signature Title WITv(t
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
Official Funeral Directors Reg.or License#