Murphy, Miriam NEW YORK STATE DEPARTMENT OF HEALTTi 1
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Vital Records Section Burial - Transit Permit
Name First(', dle Last Sexes" D
Date of Death Age If Veteran of U.S. Armed Forces,
I �1�o 1 1 l / V v
1 Place of Death 1 Hospital, Institution or City, Town or illage �S (�}....) Street Address f n /'lt� I /_ �,
Manner of Death II-,atural Cause ❑Accident El Homicide El Suicide Undetermined ❑Pending
In
fa
Circumstances Investigation
w Medical Certifier Name Title
0 JV c .DGJLsoch (—-iV
Address
i 103 6—e-,ne'S _ U4& Qy (39)1
Death Certific A..Ei ed District Number Register Number
City, Town or Village Oc 5 nut 3Z3('t ap
0 Burial tote Cemetery or CrematorK
‘017-t' 7-014 c)\n Z VI ei-v 2(Yn«
['Entombment Address
'Cremation C Q e�� C 1 i `0Y
Date Place Removed
Removal and/or Held
and/or Address
IZI U
Hold
0 Date Point of
la❑Transportation Shipment
0 by Common Destination
in Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
niiii Permit Issued to l I� Registration Number
WE Name of Funeral HomeM -� ri 9G)
Address GX 7 S t afc Ett 30 l no uvk L_'- l l a t o.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
l
II. Permission is hereby granted to dispose of the human remains described above as indicated.
ip Date Issued /D- do Registrar of Vital Statistics �j�� n.e..,_
//�I1' �'6 V ��WY1 k-lam
(signature
Mi District Number g 7 Place OA�
./�� 76 /3 c�9KI certify that the remains off the decedent identified above werelerisposed of in kcordance with this permit on:
LEI Date of Disposition /o/Lf!if Place of Disposition -4e i k./ erft.ivior....
(address)
Ili
CC (section) ,(lot number) (grave number)
pName of Sexton or Person in Charge of Premises a„,t Dim°
(please print)
Signature �� Title CRthu t
(over)
DOH-1555 (02/2004)