Murphy, Thomas 1(50
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas J. Murphy Male
_' Date of Death Age If Veteran of U.S. Armed Forces,
March 18, 2012 65 War or Dates Vietnam
i•r,
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 27 Walnut St
tit
ci; Manner of Death X Natural Cause 1 I Accident Homicide Suicide Undetermined Pending
la Circumstances Investigation
u' Medical Certifier Name Title
P. Paul Backman Dr.
Address
°:3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register`Number
:; City, Town or Village Glens Falls 5601 ! a
❑Burial Date Cemetery or Crematory
March 20, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road,Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
I= Hold
N
0 Date Point of
coTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-.' Permit Issued to Registration Number
, Name of Funeral Home Singleton-)Mealy Funeral Home 01596
;e1 Address
407 Bay Road, Queensbury, NY 12804
]_° Name of Funeral Firm Making Disposition or to Whom
F+1 Remains are Shipped, If Other than Above
Si Address
d3 C
',, Permission is hereby ranted to dispose of the humremains escrib'above as in'icate•.
Date Issued Qapj/� Registrar of Vital Statistics � f i 421'je--
7 / (signature)
District Number 5601 Place Glens Falls /�y /t7`7/
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
W Date of Disposition 3 D3— jtz Place of Disposition 3 eu i"ew � mart urn
Ili
(address)
Cl)
C .1.5.159.W
g � o 2Ile t number) (grave number)
Name of Sexton or Person in Charge of Premises �'
Z f/�": / (please print)
W
Signature Title Crep,&4or7 5 .
(over)
DOH-1555(02/2004)