Murphy, Ann (p$1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirstP) MiddleLast
) Sex-
:;,,.„ to f Death A� If Veteran of U. . Armed Eorce r
�a �� 1l War or Dates
i-- lac- • Death ^� Hospital, Institution or
Ci -, Town r Villag r l Street Address ' 4; 1--Lis, , 1s J,H-t.
1 Ma - - . Death tural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
ig Me a rtifier e 'J . Title
io
rqC up�4 Q la-�Deat. --- icate F � tDistrict I ut'nber Regist Number
Ci , Town •r VillaFdj�(c 5-7 5 S❑Burial Dat / Ce to 1ematory / "�v`ti_Art:: ;❑Entombment II ( �yAddL�I n 9 /9. d D
remation �
Date ' Place Removed
Z ri 1—land/or Removal and/or Held
Address
I= Hold
it)
O Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to n Registration ;kt•ber
Name of Funeral Horr�e-on j tj�.P i1 Gt_I/ tyvi•e_ N I/ T
Ares Jj
Name of Funera Firm Making isposition osition or to Whom
Remains are Shipped, If Other than Above
a Address 4
I
LEt
t Permission is he eby an d to dispose of the human - •'ns described abo as in 'cated.
Date Issued Registrar of Vital Statisti• . t.f)
-- (sign ure) QZ-V
District Number7J•z'5 Place / ,Jr) / r
I certify that the remains of the decedent identified abov were disposed of in accordance with this permit on:
P I Disposition ^'V` (.� rcJQ�r-i lEf Date of Disposition Ic(3i� t Place of
(address)
BLit
tO
CC (section) ``/ lot number) (grave number)
Ct Name of Sexton or Person i Charg of Premises
C Lr•,t `S'�"�+4
2. (pl ase print)
# Signature Title crilfrisi6
(over)
DOH-1555 (02/2004)