Crawford, Robert NEW YORK STATE DEPARTMENT OF HEALTH 3 7
Vital Records Section 4 Burial - Transit Permit
i. .
Name First Q Middle Last Sex
I\cT 1/�k y r C M _Y1 �c-rw ir-r
Date of Death _ Age If Veteran of U.S. Armed Forces,
apt 11 12.c4 -1 1 War or Dates onV-vnuwn y caf,-
1 P . - of Death Hospital, Institution or
,110 own or Village &- '`n5 --CA.\\ '' Street Address GLa,nS c \L\S- -r5i, }-c• I
CI 'anner of Death m Natural Cause 0 Accident El Homicide 0 Suicide Undetermined ri❑Pending
LEE Circumstances Investigation
III Medical Certifier Name Title
:-N\\ S\-tmv rb.3 N\
Address
102 po,r1L s -c,.9.3.)-.0 , 1.2zc
Death Certificate Filed District Numb r Register um�jer
City, Town or Village slpo/ sod
OBurial Date Cemetery or Crematory
['EntombmentQ5 I ►Lo I zo i ' ';r� \, e.'J Om.d 3Zinr './
Address a iii (Cremation Ci�d..\(.A.'r -oae\ CV e-Q-c,S\- - i cV- I _ �/
O /
Date Place Removed J
Z Removal and/or Held
9❑and/or Address�
tO
Hold
0 Date Point of
to Q Transportation Shipment
G by Common Destination
Carrier
i, Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
!iiiiiiiiPermit Issued to �j �- Registration Number
Name of Funeral Home l -ti*e r t-iceci o,.\ No fn t C 11 -O
Address ,\ LoSalc - - (_c_s\ i-Tho: 7 ) Ny 1Z011
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
11
111
W.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 51 16 l i '6 Registrar of Vital Statistics (jk)c1 u '
(sign
gi District Number 5 b Q 1 Place 6 s ` l S r v
,. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 51 I11j‘ Place of Disposition 'frnds
� �
2 (address)
U1
0
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge o Premises rtpj, e $Y
( lease print)
Z flat
Signature //� Title
(over)
DOH-1555 (02/2004)