Murphy, Virginia NEW YORK STATE DEPARTMENT OF HEALTH # (1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia Mary Murphy Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 2,2012 74 War or Dates
_.: Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hos I ital
cManner of Death X Natural Cause Accident n Homicide Suicide Undetermined 1 Pending
U3 Circumstances Investigation
Lij Medical Certifier Name Title
Darci Gaiotti-Grubbs MD
Address
102 Park Street Glens Falls,NY 12801
Death Certificate Filed District Number RegisteX Number
_° City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
January 4,2012 Pine View Crematorium
❑Entombment Address
OX Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H" Hold
Cl)
0 Date Point of
O.
_Transportation Shipment
a by Common Destination
Carrier
!Disinterment
Date Cemetery Address
Date Cemetery Address
n Reinterment
y Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01443
t• ie Address
• f 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cd
di
Permission is hereby granted to dispose of the human remains descr'bed abov sin d.
Date Issued L�l CV20/Z-- Registrar of Vital Statistics � r
f/ (signature)
•' District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z (( /"
W Date of Disposition 1- I, it Place of Disposition 2-Vi.o (aListi S iorwk..
W
Nre (section) (lot number)c (grave number)
O• Name of Sexton or Person in Charge Premises r,51-41/41#C :AA rtti.
Z (please print)
Z
W Signature 4,.._ Title CizeMtv-Ua--
(over)
DOH-1555(02/2004)