Murphy, Jerome P NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last...... Sex
Jerome P. Mur h :Male
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Date of Death Age H Veteran of U.S.Armed Forces,
Ma..:...::6.:1 1989 75 War or Dates No
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Z, Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
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Cause of Death
Large Bowel Obstruction
471: Medical Certifier Name Title
David W. Schwenker MD
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Death Certificate Filed District Number Register e
Ir
City,Town or Village ((L
Date :. Cemetery or Crematory
❑Burial May 8, 1989 Pine View CremAto
Cremation
Address
Quaker Rd. Queensbury, NY. 12804
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z Date Place Removed
0i El Removal
and/or Held
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Address
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: Date Point of
M ❑Transportation by Shipment
Common ............................. ............................................................................................................................................................
mon Carrier :.:.::..::.:::............. __........... ....:.:
Destination
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❑ Disinterment Date Cemetery Address
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El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm McHenry & Roberts Funeral Home Inc. 01 625
Address::::::.................................................................................................................................................................................................................................................
3 Mettowee St. , Granville, NY. 12832
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ameoFuneral FrmMak'n9DsPositior V
Remains are Shipped, If Other than Above
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Address
Permission Is hereby_ granted to dispose of the human remains escribed abo a as Indicated.
' Date Issued Registrar of Vital Statistics
(Signature)
District Number d Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W' Date of Disposition -" Place of Disposition /t�✓ ��4, �/PiFy//�T6P/�!1/i�►
(address)
W.
(section) (lot number) (grave number)
p; Name of Sexton or Person' Charge of Premises .r;N,/�I D IVIY 2/ ,-'> /
z (please print) T
w Signature Title if
DOH-1555(9/86)p 1 of 2(formerly VS-61)