Craw, Alan NEW YORK STATE DEPARTMENT OF HEALTH 3 y
Vital Records Section _ Burial - T ansit Permit
Name First 6 Middle Last C-Cq Sex /V(
Date of Death Age n If Veteran of U.S. Armed Forces,
0Li 1ZZ.IZ 0 l VI C) War or Dates tl43 \ `1' {C
Place ofDeath Hospital, Institution o 1
ii City, Towir Village C LA ec'�S -. Street Address 5 N I C�r)
Manner o Death Natural Cause D Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
iii Circumstances Investigation
tu Medical Certifier Name Title
0
Address
Death Certificate Filed
City, Town or Village c•-•
District Number Register umber
U Per s. 6... r 5451 s Lf
❑Burial Date 1Cemetery or Crematory,..) ^
['Entombment ?Co 1 2 `� \'le J e,.) U C r�� - -
Address Q
remation Q,,t,)un ! ,,,k 1 Q\ P,v,S�u>� 1`� i -g�`/
Date Place Removed
❑Removal and/or Held
and/or Address
f=` Hold
0 Date Point of
r1n Transportation Shipment
E by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to (1� ` \ Registration Number
Name of Funeral Home I' I C 1 m ef CAY�^C� I'6m d\ 0 -41S'
Address rZO `.'lP `° 'n 5 ' , (3 . c Uf-AS le l S\ MI 1 2 gb 3
Nii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
til
Permission is hereby granted to dispose of the human rem ' s " o a nd' ated.
Date Issued 4.L -Ice Registrar of V. I Statistics 4s
(signature
11 District Number j( Place DID Dia,...„,0L. !�'
I certify that the remains of the decedent identified abov re disposed of in ccor nce with this permit on:
k
ILI Date of Disposition f IZ7 Jib Place of Disposition -,F __ 44
(address)
111
iM (section) (lot number) (grave number)
0
Name of Sexton or Person in Charge of Premises AIL(please print)
iLi Signature Title MiP
`2.
(over)
DOH-1555 (02/2004)