Bromley, Mary NEW YORK STATE DEPARTMENT OF HEALTH, } -4 CY7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Elizabeth Bromley Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 29, 2012 86 War or Dates
�-- Place of Death Hospital, Institution or
tt!`' City, Town or Village Hudson Falls Street Address 1 Spruce Street
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
LU Circumstances Investigation
0
W Medical Certifier Name Title
C1 Amy Hogan-Moulton_MD,
Address
2 Broad Street Plaza Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village .5 '7 a. to i A
❑Burial Date Cemetery or Crematory
DecemberC 2012 Pine View Crematorium
❑Entombment Address I►
t(Cremation Quaker Road Queensbury,NY 12804
A_ Date Place Removed
r ri Removal and/or Held
and/or Address
F, Hold
O Date Point of
eLEi Transportation Shipment
(1) by Common Destination
0 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
I-' Remains are Shipped, If Other than Above
Address
WCL'
Permission is hereby granted to dispose of the human remain described above as indicated.
Date Issued IQ -4_go l a Registrar of Vital Statistics
(signature)
District Number S '7 a(o Place N "\ii sjiiip-cr _ ey/ -)-1., Q 0 _
L_,L.„
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W'i Date of Disposition I Z.-S tt Place of Disposition ��U�.) r! w vr ►•/
2 (address)
W
0
W (section) A . (lot number) (grave number)
O �fpl
t Name of Sexton or Person in Charge of Premises n$ P.aft
please print)
Ili Signature Title [Imo'MPV L
(over)
DOH-1555 (02/2004)