Murphy, Thomas NEW YORK STATE DEPARTMENT OF HEALTH t ♦• --1'1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Michael Murphy Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 27, 2014 73 War or Dates
Place of Death Hospital, Institution or
:! City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
M• edical Certifier Name Title
Dr. Eric Pillemer,
Address
100 Park Street Glens Falls, NY 12801
D• eath Certificate Filed District NumI� 0 1 Register Uu ber
City, Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
January 28, 2014 Pine View Crematory
❑Entombment Address
i; ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
,. Ill Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
74
P• ermit Issued to Registration Number
N• ame of Funeral Home M. B. Kilmer Funeral Home 01079
1 Address
82 Broadway, Fort Edward NY 12828
M Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
k,
:' Permission is hereby granted to dispose of the human remains described above as indicated.�ld.
j t L Registrar of Vital Statistics CA ti-y Q k./�1�`-cio
Date Issued I / z8'� _U , `_
(signature)
District Number 560 1 Place o �S I S , 1� y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/28/2014 Place of Disposition • Quaker Road Queensbury,NY 12804
(address)
(section) lot number (grave number)
Name of Sexton or Person incharge of Premises ros1, '( et,*
(please print)
Signature Title (17‘06.47/
(over)
DOH-1555 (02/2004)