Broda, Margaret s �y1 (4 0
NEW YORK STATE DEPARTMENT OF HEALTH �
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Margaret L. Broda Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 2, 2013 58 War or Dates
,! Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
GManner of Death I XI Natural Cause Accident [1 Homicide Suicide n Undetermined Pending
Wi Circumstances Investigation
G Medica ertifier Name Title
Addres
A )a'Sr ) I
Death Certificate Filed t District Number Registe,.lyum er
City, Town or Village Glens Falls,NY 5601
El Burial Date Cemetery or Crematory
November 5, 2013 Pine View Crematory
El Entombment Address
ll Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
a Address
et
4. Permission is h re y granted to dispose of the human remains described abovelas indicated.
Date Issued/ 6r73 Registrar of Vital Statistics C _Q U0..0
(signature)
District Number 5601 Place Glens Falls,NY 4210/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition Ilr(4t Place of Disposition 4nj Iry C-rtc.w_
W (address,
co
0 (section) (lot number) (grave number)
Op Name of Sexton or Person in Charge of Premises II,� (,_. ,3t,,,14-
Z (please print)
W �f
Signature LI, C>_ Title
1
(over)
DOH-1555(02/2004)