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Brophy, Marilyn NEW YORK STATE DEPARTMENT OFHEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Marilyn S. Brophy Female Date of Death Age If Veteran of U.S. Armed Forces, July 21, 2017 92 War or Dates Place of Death Hospital, Institution or L1T City, Town or Village Hudson Falls Street Address 7 Broad Street WManner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title Mary Kilayko, MD Address Queensbury, NY 12804 Death Certificate Filed District Number Register Number City, Town or Village <5-7 6 l� ❑ Burial Date Cemetery or Crematory July 17, 2017 Pine View Crematorium ❑ Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z Removal and/or Held and/or Address .. Hold C Date Point of ❑ Transportation Shipment U) by Common Destination Cl Carrier Date Cemetery Address ❑ Disinterment ❑ Reinterment Date Cemetery Address 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 I— Remains are Shipped, If Other than Above 2 Address W O Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued � , -.)le/7 Registrar of Vital Statistics •ts�,, j (signature) District Number Si,?'.,C, Place ,1/ a I�A.1J - I certify that the remains of the decedent identified above were disa�pposed of in accordance yvith this permit on: W Date of Disposition 07/-V/2017 Place of Disposition Quaker Road Queensbury,NY 1280'4 (address) W fl? ce (section) (lot nuyber) (grave number) a (..� t Name of Sexton or r on in Charge of Premises ^ ' `'� 4 rsiGG'1�� (please print) W Signature AV../ Title G c (over) DOH-1555 (02/2004)