Bergmeier, Jane Marie PERMIT NUMBER
A COPY OF THIS PERMIT MUST STATE OF ARIZONA
ACCOMPANY THE BODY TO THE
FINAL DESTINATION. DEPARTMENT OF HEALTH SERVICES-BUREAU OF VITAL RECORDS
DISPOSITION TRANSIT PERMIT
DP202D-002843
1.DECEDENT'S LEGAL NAME(FIRST,MIDDLE,LAST,SUFFIX) 2.SEX 3.DATE OF BIRTH 4.DATE OF DEATH
IDENTIFICATION JASON,MICHAEL,COMMISSO MALE 09/21/1978 01/09/2020
OF DECEASED 5l PLACE OF DEATH-CITY OR TOWN 6.COUNTY 7.STATE
MESA IMARICOPA JAIRIZONA
8.NAME AND ADDRESS OF FUNERAL FACILITY OR PERSON RESPONSIBLE
ALL OPTIONS FUNERAL HOME
1525 W UNIVERSITY DRIVE#SUITE 102,TEMPS,AZ 85281
9.NAME OF FUNERAL DIRECTOR OR RESPONSIBLE PERSON
MANNER AND PLACE SAVANNA,H,ARRIAGA 12.DATE F DISPOSITION
OF DISPOSITION 10.METHOD OF DISPOSITION 11.NAME AND LOCATION OF 1 DISPOSITION FACILITY
PINE VIEW CREMATORY, 01/15/2020
REMOVAL/CREMATION QUEENSBURY,NY,US
13.METHOD OF DISPOSITION 14.NAME AND LOCATION OF 2 DISPOSITION FACILITY 15.DATE OF DISPOSITION
1I116.MEDICAL EXAMINER'S AUTHORIZATION FOR CREMATION 17.DATE OF AUTHORIZATION
AUTHORIZATION ICAROLINE,'L.,CROSS 01/14/2020
A.A.C.R9-19-313 REQUIRES THAT A PERSON IN CHARGE OF A PLACE OF FINAL DISPOSITION IN ARIZONA SHALL MAINTAIN A COPY OF THIS DISPOSITION TRANSIT PERMIT AT THE
PLACE OF FINAL DISPOSITION FOR AT LEAST FIVE YEARS AFTER THE ISSUE DATE
VS-8 Rev.7/2017
i
Public Health Law Sec. 4145(2b) 13267
Receipt
Human remains of :�t�: delivered on , 20
r•
Pine View Cemetery t� Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#