Murphy, Eileen NEW YORK STATE DEPARTMENT OF HEALTH , • �'[
Vital Records Section Burial - Transit Permit
Name First Middle ' Last Sex
Eileen M. Murphy Female
Date of Death Age. If Veteran of U.S. Armed Forces,
September 20, 2015 67 b War or Dates
Place of Death A Hospital, Institution or
City, Town or Village Street Address The Gateway house
Manner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
• Circumstances Investigation
Medical Certifier Name Title
a. John P. Stoutenberg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
j Death Certificate Filed District Number �I Register Number 44
. City, Town or Village
-;❑Burial Date Cemetery or Crematory
September 23, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
R❑ Removal and/or Held
. and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
41
�°�❑ Reinterment Date Cemetery Address
r Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reb `graanted to dispose of the hum s describe• •ve as indicate --�
Date Issued q 1,tRegistrar of Vital Statistic � Lc `INC .�L�-
(signature)
District Number /p' Place —r,�,, N.),040,e,,
. :;;
2 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
; Date of Disposition 09/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numb (grave number)
Name of Sexton or Person in Ch ge of Premises t'/;)
(please print)
Signature Title MNI1911
(over)
DOH-1555 (02/2004)