Broderick, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
DorothY:::::.-..::.::::::.::::.::::..::::::::::::::::::::::::::::.:::::::::::::::.:::::::::::::.:::::........._ Broderick . ...._.__......... ......... F
. . . :..............................
Date of Death Age If Veteran of U.S.Armed Forces,
War or DatesNo
... ........::::::.:::::::::::................,
Place of Death ................................
Z ; Hospital, Institution or
City, own r Village Elizabethtown Street Address Elizabethtown Hospital
Cause of Death
t3]
: :Ao:u:::e:::Car...lac::.Arrest::.............::::::::::::::::::::::::.:........:::::::::::::::............::::...... _....... ................................................. _.......
Medical Certifier Name Title
Herbert Savel MD
.....................................:Ad d re ss.:::::.......................................................................................................................................................................................................
Elizabethtown..N.Y. 12932
...
Death rtificate Filed District Number : Register Number
City,C OQ or Village Elizabethtown 1552
Date Cemetery or Crematory
❑Burial 5/11/89 Pine View Cremator
:::.:.:...........:......::.:....:::::............:...:..::::::.Y::..............
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[]Cremation Address
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Z, Date Place Removed
❑ Removal and/or Held
and/or Hold :::::::::::.........:....::::::::.::......:......::......::::::::::::.::::::::::::........................:...................._.........:.:::::::::::::..:::.,
Address
Q::.::::::::::..:::::............_ .........................:.:::...........:::......:::::::::::::::::::::::::::::...................._................_......._......_..._.................................._............_...._....._.. ......_._.._...
tLl Date Point of......
f................................................................................................................... .........
N!! []Transportation by:. Shipment
Common Carrier [ ............................................................................................................................................
❑; ......:...:.......... ..... .....................
Destination
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.................:..::.......:.......... .... .............................
El Disinterment Date Cemetery Address
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❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm W.M.MARVIN"S Sons Inc. 01552
...............
Address::::::..................................................................................................................................... .............................................................................................
Elizabethtown.:.N Y.......12932._ ..... ._ . .... .............. .............................. ......_.............. .._._.
:4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ftt:[
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5/11/89 Registrar of Vital Statistics 1
s ature)
District Number 1552 plate Elizabethtown,N.Y.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition /oZ"b'/ Place of Disposition /Pi /✓�'�.c�lcJ �/�.��/4�i1�/U/�
ii (address)
w
(section) (lot number) (grave number)
p Name of Sexton or Person i har a of Pre ises -,�
Z; (please print) /fJ 6/� c�s//
W Signature Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)