Murray, Michael 2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section 0 Burial - Transit Permit
Name First Middle Last Sex
Michael Riley Murray Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 24, 2017 72 War or Dates
Plac ath Hospital, Institution or
City own r Village ' I) 5 c, L v -4,1 Street Address 3159 Route 4, Apt 16
Manner of DeathLxim Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined 0 Pending
Circumstances Investigation
Ws Medical Certifier Name Title
a Michael Sikirica MD,
W
n= Address
50 Broad Street Waterford, NY 12188
Wi Death Cate Filed \ / District Number Register Number
CityClownftt Village K., •r) s b( c.-u-/, 5 (Q 3• 0 5?t ❑Burial Date Cemetery o rematory
March 27, 2017 n e feu) cc,, ' ' / _ "�"'
3❑Entombment Address
it ®Cremation 't,{ -e0 6 I I A)44
Date Pla Removed
Removal and/or Held
and/or Address
ppi Hold
Date Point of
t3.,❑Transportation Shipment
by Common Destination
r, Carrier
., Date Cemetery Address
❑ Disinterment
`❑ Reinterment Date Cemetery Address
'11`r Permit Issued to Registration Number
41 Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
,,,,,, Name of Funeral Firm Making Disposition or to Whom
hi Remains are Shipped, If Other than Above
Address
ei tl>';
Permission is hereby granted to dispose of the human remains scribed above as indicated.
Date Issued 3 -c)7 -ad/7 Registrar of Vital Statistics .p t. o .L_
(signature)
lii District Numbers 7� a Place i Ct.-4,,- Vi'rt '.„
5...
,_,,,,
I certify that the remains
ZZog�f�the decedent identified abo were disposed of in accordance with this permit on:
eDate of Disposition 03/ 017 Place of Disposition �,,J Crern4 /
L�= p P 211c��
` (address)
tut
a (section) (lot number) (grave number)
Name of Sexton or erson in Charge of Premises
�t"'��4-✓' ���
(please print)
Signature ` Title ��'L �
(over)
DOH-1555 (02/2004)