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Jarvis, Michael If 702_ ,Ycvv ruHK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section t Name First Middle Last 1 Sex Date of Death 1 Age ( If Veteran of U.S. Armed Forces, l` ��*a1-5- ; S ? War or Dates lace of DeathV�k4--\ I Hospital, Institution or � E Town or Village G ' !_ cCI,\\s ! Street Address )C'Y15 l+21 Manner of DeathLAtt Natural Cause C Accident ❑Homicide fl Suicide u Undetermined ending Circumstances investigation `:' Medical Certifier Name Title __ kQ Canal �1Q,Y1Q ' \ In S� Address �.J 1i-Y n3cY - Cer142r 1 r--1-ecl S Palls 1 j 1 z O) Death Certificate Filed District Number �- { Regis er Numberiiis r�� ar >`' Town or Village G�.Q.Y1S . -C.O\c ? .1�-�1 1- 1 Date I Cemetery or Crematory -:: ❑Burial 1 ©C}, 2 j 1 1-C31S Pine- V 1 ekk) Crerna e 1 I �q } /Address � ::: Cremation 1 Y 1`_ 1�Q�Y1 L r y lq 1 1 SQ 1 Date Place Removed 1-12 Removal ( and/or Held and/or _ .�_._ --__ .._.�____._._...___ Hold I Address 0 1 Date =c;int.o; ai 0 Transportation i _____ _. Shipment Q by Common 1 Destination Carrier i i -:-:: 1 1 Disinterment 1 Date y Cemetery Address t Reinterment ` Date Cemetery Address 1 1 Registration Number `:><' Permit Issued to 15Cc er Fe-trieia home- Name of 3 _ Funeral Home 1 C( i 3� icg Address r'' J cI Name of Funeral Firm Making Disposition or to Whom :, Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human mains described Bove as ind- to .'<= Date Issued 00.5/.. .-i,„ -• Registrar of Vital Statistics>` < ( tg to ) f` Place >" District Numberpf / I certify that the remains of the decedent identified above were disposed of in acc dance with this permit on: f .ii y� Date of Disposition VAC-t+r Place of Disposition � t it x. rer-**'- M (address) 141 M (section) /y(lot number) (grave number) CName of Sexton or Person in Charge of Premises (St S't t 2 4 I (please print) #L Signature Title +1GN114 a� {oven DOH-1555 (9/98i