Crawin, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH
Burial - Trans e rmit
Vital Records Section B u
Name First Middle Last Sex
It.. o k C r a tN% ✓v Pt-
Date of Death Age If Veteran of U.S. Armed Forces, _
y- 2 y-/3 9 3 _ War or Dates
1.i- Place o eath f locpit Institution ir
ow - ♦ "17;Ye
W ow �ti �C.XaI rJ� � W.A i'Al* 4 U,1 -
O Manner of Death W Natural ause ❑ ccident ❑Homicide ❑Suicide 0 Undetermined ❑Pending
U Circumstances Investigation
W Medical Certifier 41 le /' 1 Title
.Q�t.✓i U r !G(1 u(/w )0Address �/ e 110
U t,t�
11
Death Certificate Filed District Number J Re ist umber
,_Git ow e , - q 5l g51
❑Burial Date I Cemetery or Crematory j
f_,� u- 1 i 1*�. n ()I' ,P w
['Entombment Address `/
Cremation C� k n-
. Date Place Removed
Z. `Removal and/or Held
C1' and/or1. Address
H Hold
0 Date Point of
❑Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
E Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home hil luilt7,O (j r f-uitAL Wog' — OW d 1
Address
Name of Funeral Firm Making Disposition or toom
104 Remains are Shipped, If Other than Above
Address
cr
lt!
Permission is)hereby granted to dispose of the human r m ins described abqve as indicated.
Date Issued I herein/
f iRegistrar of Vital Statistics C_ Q
(signature)
District NumberS(,c c-- ) Place j cj 1 _ Q (
I certify that the remains of the decedent identified above were disposed of in accordance oil 's permit on:
Z
lv Date of Disposition 5-Z-13 Place of Disposition - zas.) Cire,n4 •
2 (address)
1i1
w
Cr (section) -(lot number) (grave number)
Name of Sexton or Person in Char e of Premises rt \��"''x�
Z ( lease print)
W 4L
Signature Title Ct u,ta-c11ti=
(over)
DOH-1555 (02/2004)