Crawford, Michael NEW YORK STATE DEPARTMENT OF HEALTH t ' k*-1 yLi
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael Timothy Crawford Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 6, 2012 25 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Hudson Falls Street Address 39 Willow Street, Apt. C
0 Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending
10 Circumstances Investigation
W Medical Certifier Name Title
O Kevin Gallagher, M.D. Dr.
Address
Granville Family Health Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village 5 - a(o o 7
0 Burial Date Cemetery or Crematory
May 9, 2012 Pine View Crematorium
❑Entombment Address
LICremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
Hold
Cri Date Point of
a. ❑Transportation Shipment
by Common Destination
p Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
• Address
Ce
W':
Cl. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -S 0 l3. Registrar of Vital Statistics -.- CA. �-e--,—_ _ —
(signature)
District Number S 7a(o Place y .e... —
I—' I certify that the remains of the decedent identified abov were disposed of in accordance with this permit on:
W_ Date of Disposition CMIR Place of Disposition .rvI > ( cit4 _
x (address)
Wco
,'
ce (section) 4,1,,_ (lot number (grave number)
O Name of Sexton or Person in Charg of PremisesZ v{"'i�
(please print)
W Signature /1171-- Title C2L MT3r'tO(
(over)
DOH-1555 (02/2004)