Murphy, Suzanne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
I<^ Name First Middle Last Sex
Suzanne Marie Murphy F
Date of Death 1 0/31 /201 3 Age If Veteran of U.S. Armed Forces,
39 War or Dates
Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending
UU Circumstances Investigation
W Medical Certifier Name Title
t John P. Stoutenburg MD
Address
102 Park Street, Glens Falls NY 12801
Death Certificate Filed District Number �(���{ Register l5ber
City, Town or Village Glens Falls <.JL1.LJ! L��
<i;E3Burial Date 1 1 /06/201 3 Cemetery or Crematory Pineview Cemetery
['Entombment Address
❑Cremation • 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
❑and/or
F- Address
• Hold
O - Date Point of
850 Transportation Shipment
ciby Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to MH Kilmer Funeral Home Registration Number
Name of Funeral Home 01078
Address136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
t;i -- --
` Permission is hereby granted to dispose of the human remains described above as indicated.
pli Date Issued j.J/i d Ls Registrar of Vital Statistics CAA.'�'Nia_A-A-1
(signature)
District Number 5 G p t Place �, (..s_,t,�s 11 S &i )
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
LEI• Date of Disposition it (d 1,5 Place of Disposition i aiL /ti,tJ 01444010-z,Lf",
2 (afdress)
LEI
2—
CC (s tion) (lot number) (grave number)
ti Name of Se on or Person in Charge of Premises LiOnlice_ ( , 6
(please print)
ut Signature L4t-ti i� Titl 04VithiA ¢ M„rA A
(over)
DOH-1555 (02/2004)