Brodeur, Margaret NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Margaret Mary Brodeur Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 30, 2013 94 War or Dates
F-, Place of Death Hospital, Institution or
Zia City, Town or Village Glens Falls Street Address The Pines
CI W Manner of Death j Natural Cause El Accident ❑ Homicide ID Suicide 0 Undetermined Pending
4.) Circumstances Investigation
Lli Medical Certifier Name Title
Ci
Address
Deat ificate Filed Distrir+ Mi'mhpr Regis+Pr Number
City, 1 �• or Village t.f1"n7 0,mt - Go / S�
NI Burial Date t 0 (3 Ceccmete or Crematory /�
ElEntombment _ i _ - +. Hipker3t.a Cam-0, „j
Address
'❑Cremation Tn of Q .i I.)cx>�
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold
a Date
O Point of
EL ❑Transportation Shipment
_ by Common Destination
a: Carrier
Disinterment Date Cemetery Address
❑ 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
1I--• Remains are Shipped, If Other than Above
2 Address
W
CL Permission is hereby granted to dispose of the human remai s described above as indicated.
Date Issued z/ 17- /3 Registrar of Vital Statistics _ P) .1_,
9`, (signature)
District Number 5 74,a- Place , nc, if �J r_ ) in 0e)
F=' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition (Pt t/13 Place of Disposition Sj d le i,v-+ 5 vs Q v,e,,r,6,-, ,4"
ill (address)
to
Et (seion) ((lot number) (grave number)
ri Name of Sexton or Person in Charge of Premises f; "` < <. ki N
ZW /) (please print)
Signature T/C Title 411 04'0 f ?'/
(over)
DOH-1555 (02/2004)