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Broderick, Mary / NEW YORK STATE DEPARTMENT OF HEALTH ' t J Vital Records Section Burial - Transit Permit Name First Middle Last Sex Mary Elizabeth Broderick Female Date of Death Age If Veteran of U.S. Armed Forces, February 15, 2017 88 War or Dates 1 Place of Death Hospital, Institution or W City, Town or Village Queensbury Street Address The Stanton HCF W' Manner of Death LI Natural Cause ❑ Accident El Homicide 0 Suicide ❑ Undetermined ni❑ Pending .? Circumstances Investigation CI Medical Certifier Name Title Kenneth France, Dr. Address 170 Warren Street Glens Falls, NY 12801 De •� icate Filed Di ict Number st r Number Cit , Town Village kl, ..02- , 0 Burial Date Fn Cemetery or Crematory February 27, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held a and/or Address E Hold () Date Point of eL ❑Transportation Shipment byCommon p Destination O Carrier Date Cemetery Address El Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped, If Other than Above 2 Address IX W, a" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued l 1rTh lam)--)Registrar of Vital Statistics ` jG� !L'k-'„..,,, (signature) District Numbe9S r( Place l C L.,-- C>� C.) -r\\,,,,._, �' I certify that the remains of the decedent identified above were disposed of in acco ance with this permit on: is3 WDate of Disposition 02/s`' /2017 Place of Disposition Quaker Road Queensbury,NY 12804 j//w-Llic-u/L--! rrey-/��'y W (address) Ce (section) (lot n ber) (grave number) a p Name of Sexton rso in?Charge of Premises -_J k I r C..0 ,✓s'?cz.v4...e Z (please print) W Signature ../ Title C.te.,y>4 zA. l4+r/ 0Pai's dG (over) DOH-1555 (02/2004)