Murphy, Richard NEW YORK STATE DEPARTMENT OF HEALTH
- Vital Records Section Burial - Transit Permit
>< Name Fars ,,��nn 1ddle Last Sex
-el ith rd Ctn Hckr-phu
iN Date of Death Age I If Veteran of U.S. Armed Forces, m
11.1 OS by/ 20I1,e 01 j War or Dates 55-li.)y
Place of Death f_ _ Falls- ' Hospital, Institution or 6-Lens Fails H.p1
E Ci Town or Village (j/ems Street Address jot) PQ,r t. A biei.s FA.l l:, NV-
:.:nner of Death 127 Natural Cause 0 Accident 0 Homicide ❑Suicide n Undetermined ri Pending
Circumstances Investigation
iri Medical Certifier Name Title
Sec.ri f3' a,:h r\
`< 3 Address •
lip I
100 Parr S -cee--' &ler S F \\Si /\1
<< D h Certificate Filed District Number / Registeru beer
.
Cit own or Village C�tier,� �A\\c
3
:.:: � Date �5�6� ��O/� Cemetery�r Crematory
Burial Mae V t ex.,) Ce i e
lery
Address
Cremation
- GQ►�e� A3or? i At t 8
Date i Place Removed
Removal and/or Held
and/or Address
>
Hold
0 I Date Point of
❑Transportation, 1 Shipment
ate by Common Destination
Carrier
Disinterment
Date Cemetery Address
n Reinterment 1 Date Cemetery Address
_ Permit Issued to _ Registration Number
Ihr Name of Funeral Home ._ _ . Rp.t& = ,$)eri.43-L, M,1 - 0l159 -
: Address / >
"d Name of Funeral Fym Making Disposition or to Whom r -
Remai
ns are Shipped, If Other than Above
Address
'3 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued S /`- 12 016 Registrar of Vital Statistics W C'WYrs4
// (signature)
=r`gii: District Number 5 U 0 1 Place C �us ) V\5 r N�d�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 5/6/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
Seneca 24G 1
CA
(section) (lot number) (grave number)
GName of Se on or Person-in Charge of Premises Connie .L. Goedert
Z (please print)
W Signatur ' keLc..2_. ., _P_6 -svi\ Title Cemetery Superintendent
(over)
DOH-1555 (9/98)