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Jarvis, Loraine Dorothy l NEW YORK STATE DEPARTMENT OF HEALTH ' - Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Loraine Dorothy Jarvis Female Date of Death Age If Veteran of U.S.Armed Forces, 10/29/2020 86 Years War or Dates j.,. Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc 0 Manner of Death 0 Natural Cause D Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending ILI Circumstances Investigation W Medical Certifier Name Title Carrie Miron PA Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 92 ©Burial Date Cemetery,Crematory or Facility Name 11/02/2020 Pine View Cemetery ❑Entombment Address ElCremation Queensbury,New York Donation O Removal Date Place Removed and/or and/or Held F— Hold Address N N ❑Transportation Date Point of p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address CC Ill IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/02/2020 Registrar of Vital Statistics 2imee1falrortey(Electronicali:y Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1 Date of Disposition 11 /2/2020 Place of Disposition 21 Quaker Rd. Queensbury, NY 12804 2 (address) W Seneca 23D 1 to Ir (section) (lot number) (grave number) g `� Connie Goedert Name of Sexton erson in Charge of Premises (please print) Z W Signature % i is it - ? Title Superintendent DOH-1555(o7/t8)p t of 2 Public Health Law Sec.4145(2b) u 12 819 Receipt Human remains of\ delivered on ', , 20 ��f ,,,•'y ne View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#f , x! ,,i 1 r1 , JARVIS NAME Loraine Jarvis Age: 86 Lot Owner: Loraine D. Jarvis Lot# Seneca ��� Grave# 1 Case:Concrete Died:1 0/2 9/2 0 2 0 Interred:1 1 /2/2 0 2 0 Funeral Home: Singleton, Sullivan, Potter FH Cemetery: Pine View