Murphy, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Arm d F ces,
War or Dates
Place of D ath Hospital, Institution or
City, Tow 'or Village C ����, f0.�>'s— Street Address
Manner of Death n Natuu C use ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
If 44' Circumstances Investigation
Medical Certifier Name Title
qv SG Wa,1.'e C !''I • D .
Address
Death Certificate Filed / District Number Register Number
City, Town or Village Cr CeK� 4
Date Cemetery or Crematory
❑Burial `7� a 17
Address
Cremation C /oi
Date Place Removed
8 ❑Removal and/or Held
—. and/or Address
Hold
0 Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home arc-
Address
Name of Funeral Firm Making Disposition or to Whom '
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described abo a as i isaate_d.
Date Issued a Registrar of Vital Statistics � �
(signature)
District Number JL Place L,?l
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
iF-
F Date of Disposition Place of Disposition �i/J,E" l//riFk� C�i��/Yli2 ��i /F��
r (address)
l�
M (section) (lot num r) (grave number)
0 Name of Sexto or Perso in Charge of remises ,�,17A,6; P m,617 1,
g (please print)
Signature Title C—we 70-1? � '
DOH-1555 (10/89) p. 1 of 2 VS-61