Jarvis, Charles rr i
NEW YORK STATE DEPARTMENT OF HEALTH J' 5'03
Vital Records Section Burial - Transit Permit
• Name First C r^ rt S Middle �� Last �C �l t S ` Sex N
%I Date of Death
u::: y L�i� Age o tf Veteran of U.S.Awned Forces.
'' I War or Dates 19y 3-1
Place of Death
s Institution or
� ���� ageQ �1_Q. lbl� --
�iC C,l_rol'Ire_ &.
' Manner of Dea Natural Cause fl Accident 0 Homicide 0 Suicide nUndetermined Q Pending
IA
Circumstances Investigation
Medical Certifier Name Rs) Title
grig Address ryry�� i •
1 -.XO( C t Cf2 erg6unS= S ,iO4 12. b\
4" Deal -mate Filed QI,t�SZ n District Number •
`'# ' r Village Cx( � Register Number
ot
Date Cemetery amatory
ID Burial \ R i2_015 1.---i f c U i e.is-)
-.- Address
rsmatiorr__. __-
Date Place Removed "
Removal and/or Held
p and/or Address
a Hold
Date Point of
a ID Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
`'a Permit Issued to _ ) Registration Number
Name of Funeral Home _.._.. _ g,I it e--t i"u,.seit.ser_ANC"" o j 13c
: < Address
/1 dL A 6-T Th Ci 0 t l :.lS S U 12$3 f
`� Name of Funeral Fi Making Disposition or to Whom t -
:5, Remains are Sig . If Other than Above
AddressILI
p
t
`k>= Permission is hereby granted to dispose of the human remains described above as indicated.
�::> - Z d' Date Issued �'(I- 'DOO 1� R+agistr�r of vital Statistics -" a-"U‘'1\ __ __— ___^_ _--
(signature)
`ti' District Number 5 ..0 51 Place ..3 J e S byi(.
=:= I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
Date of Disposition 1 J leJI x- Place of Disposition (address)
��U� /�i�.-ides~
LU
til
CC (section) /%( •nten (grave number)
nName of Sexton or Person in Char of Premises L^°t red,
g (please print)
4t Signature Title fi na
- (over)
DOH-1555 (9/98)