Brodeur, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kathleen Rose Brodeur Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 26, 2013 93 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ill Manner of Death Natural Cause ❑ Accident 0 Homicide 0 Suicide 0 Undetermined ri I---' Pending
(:o CircumstancesInvestigation
WW Medical Certifier Name Title
Howard Silverberg, MD,
Address
Department of Medicine Fort Edward, NY 12828
Death Certificate Filed District Number Reaister Number
City, Town or Village
®Burial Date s e Cemetery or Crematory
u e l � ST. ALPHONSUS CEMETERY
❑Entombment Address
'❑Cremation Town of Queensbury,NY
Date Place Removed
❑ Removal and/or Held
and/or Address
_p Hold ST. ALPHONSUS CEMETERY
CO Date Point of
0,, ❑Transportation Shipment
_ by Common Destination
C Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
1
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
IX
Ui
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /J. /7- /2 Registrar of Vital Statistics ,_ 0_,0 -
(signature)
District Number S '71p�- Place /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition
alp 6: i 1 13 Place of Disposition 5-4- 0 I n`�idr,Sys �vcGn,r 6y�• O✓�
1_ (address)
wO
P
at (sec . n) (lot number) (grave number)
AA- ke
0 Name of Sexton or Person in Charge of Premises (a v. L
Z (please print)
W Signature (-7 Title in 4-N ay e--
(over)
DOH-1555 (02/2004)