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Jarvis, Shirley NEW YORK STATE DEPARTMENT OF HEALTH "'' 4 # 37Z Vital Records Section Burial - Transit Permit Name First Middle Last Sex Wirt. 4, .� L `�t ,JPC- Tem-Li) S I' /1�921r Date of Death Age ( If Veteran of U.S. Armed Forces, 3'1. 1/3 �9 j War or Dates ,J/a. Place • .-ath I Hospital, Institution or City, Town%r Village t 66,0S Q u s,L/ Street Address 17 C ai2,V n K Q 1-- till - � Manner of Death©'Natural Cause 0 Aobident 0 Homicide 0 Suicide n Undetermined Pending Circumstances Investigation Medical Certifier Name Title g- N/� IL in J. Genrd- J,_ 4. . Address 327 a r. Lr()w b �l i z�2 Death Certificate Filed Di t umber Regi er Number %r' City, ow Village Q 0 br- ,U s 6 arty lc.. '1 Date Cemetery or'remator ❑Burial Sjh AS' /� Address 01 LCremation Q 0 4-Z.._to*K... -re-4 - - Q 0 14--e-,Js a U 7 Date Place Removed 2 710❑Removal and/or Held and/or Address — Hold 0 Q Date I Point of Fni n Transportation j Shipment fl by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address I Permit Issued to _ / Registration Number s Name of Funeral Home _ RP.n.,11_ h.).,-);=, , 17 Pt 0//3O Address ai I t I-i)-. 0-y 6-7-7-c7- C-i-. 61)u61;-"),c 6 o r Ay, 1 2X-0 iiiii Name of Funeral Fiern Making Disposition or to Whom . it t Remains are Shipped, If Other than Above Address • Permission is hereby granted to dispose of the human re ains described a ve as indicated. :;a :' Date Issued i (`p ( (C Registrar of Vital Statistics �.C, �� (si nature) 11 District Number'(0S-n Place I certify that the remains of the decedent identified above were disposed of in acc rdanc with this permit on: f- � if, Date of Disposition 5 I rills Place of Disposition �i„�ik o r)_._ X (address) LU CC g (section) „j (lot numbe (grave number) • Name of Sexton or Person in Char of Premises Ar, CI (please print) f W Signature r Title ` f`Rn"t=7,,il - (over) DOH-1555 (9/98)