Jarvis, Virginia It
NEW YORK STATE DEPARTMENT OF HEALTH 4 �- 7® 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia Jarvis Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 15, 2012 86 War or Dates
°,, Place of Death Hospital, Institution or
. City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death X Natural Cause Accident Homicide fl Suicide Undetermined Pending
W, Circumstances Investigation
u Medical Certifier Name Title
' Amy Hogan-Moultan,MD
Address
2 Broad Street,Glens Falls,NY 12801
,a:" Death Certificate Filed District Number Register Number
`';' City, Town or Village Glens Falls 5601 1
❑Burial Date Cemetery or Crematory
April 18,2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
W Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
;ti l Name of Funeral Home Regan & Denny Funeral Home 01443
Address
t;j 53 Quaker Road, Queensbury, NY 12804
'tle1 Name of Funeral Firm Making Disposition or to Whom
kRemains are Shipped, If Other than Above
Address
i '
ate;
Permission is hereby ranted to dispose of the human remains des ibed abo e as • d�' ated.
Date Issued `/ 6 20/2- Registrar of Vital Statistics ~ %
(signature)
District Number 5601 Place Glens Falls
▪ I certify that the remains of the decedent identified above were disposed�7 of in accordance with this permit on:
W Date of Disposition ‘11/01l1 Place of Disposition �''tL.J C {ariu..
2 (address)
W
CO
re (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises (1rI) 1"N�' S,v,,,rit"
Z I(please print)
W Signature 7 Title CV m (O(l.
(over)
DOH-1555(02/2004)