Murray, Kenneth NEW YORK STATE DEPARTMENT OF HEALTF ' r # 79r
Vital Records Section Burial - Transit Permit
iE Name First Mi ie Last S
Ic ,�1N b"'T~,�} d 8/7 S IV U RR /7ezi�
Date of Death i Age If Veteran of U.S. Armed For s,
w J/3I cib ates AJI„),1T
P P . e of Death Hospital, stitution
' . own or Village L�,,.>,s I—oZ L S ee Address Ut e,,i s ir- LS
.nner of Death J Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
L1J Circumstances Investigation
iti Medical Certifier Name ,, Title
IP )/6, 6/er/ Lb)0 ti- /t jA
Address
I d't* 1e- --)5- Clete s fku-f}
Certificate Filed District Number Re aster Number
Cit own or Village )L.t: �l..t.J ,S 'S"(.0,
❑Burial Date Cemetery oremator
❑Entombment l Z 1//6 / / VI E: -3
gi Address
Cremation
Date Place Removed
❑Removal and/or Held
and/or
titAddress M
Hold
0 Date Point of
II Q Transportation Shipment
L. by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date. Cemetery Address
14.
Permit Issued to &,� Registration Number
Name of Funeral Home 1 6— �'v.,,) td-L_.i- ,., a 0/�t!
Address. ii Z ; ' -r. .,),,----) , Q 061,,,,,,auk „4,/, /290 ''
Name of Funeral Firm Making Disposition or to Whom 7/.
t4 Remains are Shipped, If Other than Above
Address
at
L
9" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11 ( a_) t E Registrar of Vital Statistics W C v i. ,A," U
(signature)
District Number 5 bo) Place 6 CizA...s 3 c 11 s j No
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 /�
lit Date of Disposition ill j,rL, Place of Disposition fra(i, ,,, ` l y .
(address)
Ui
Ca
CC (section) , (lot number),. (grave number)
Name of Sexton or P L erson in Charge of Premises 4 ,- e04417.
2 ( lease print)
Signature21
s Title (,s' M}t(7,ljr'
t (over)
t
DOH-1555 (02/2004)