Jarvis, Irwin t4 , # 3z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
''- Irwin George Jarvis Male
Date of Death Age If Veteran of U.S. Armed Forces,
;;s May 1,2015 77 War or Dates US Army
'''` Place of Death
�`�;; Hospital, Institution or
1Manner
City, Town or Village Queensbury, NY Street Address Stanton Nursing& Rehab Centre
of Death n Natural Cause n Accident n Homicide n Suicide ❑Undetermined Pending
Circumstances Investigation
.i Medical Certifier Name Title
Suzanne Blood,MD
Address
Glens Falls,NY
-` Death Certificate Filed District Number Register Number
Al City, Town or Village Queensbury,NY 5657 -7
❑Burial Date Cemetery or Crematory
❑Entombment ? e 's2015
Pine View Crematorium
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
C ❑Removal and/or Held
and/or Address
! Hold
U)
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
`- Permit Issued to Registration Number
1 Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
A. Address
J%r 407 Bay Road, Queensbury, NY 12804
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 rem•' 'd-scribe. -boo _ . :'indic .
f-,, Date Issued 5-��- jt< Registrar of Vital Statistics J� A. 6 �° P
�, 4
' �� (signature) —
1
f District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 5/5 I 1 c fi
Place of Disposition �(,,K,t f,� C�-r st.-
(address)
LU
Cl)
tY (section) (lot number) (grave number)
QName of Sexton or Person in Charge f Premisesr,. Ju.4pt-
W (pl ase print)
Signature Title (1>jt
(over)
DOH-1555(02/2004)