Jarvis, Robin f S 4+ to t
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Robin Lee Jarvis Female
Date of Death Age If Veteran of U.S.Armed Forces,
October 12, 2013 57 War or Dates No
k- Place of Death Hospital,Institution
Z City,Town or Village City of Albany or Street Address Albany Memorial Hospital
LU. Manner of Death Natural Undetermined Pending
W Accident ❑ Homicide ❑ Suicide ❑ ❑
® Cause Li Investigation
W, Medical Certifier Name Title
C Mamie Caton MD
Address
Albany Memorial Hospital, 600 Northern Blvd., Albany, NY
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1933
Date Cemetery or Crematory
❑ Burial October 16, 2013 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
I- Hold
N:
Date Point of
a' Transportation Shipment
Cl) ❑ By Common 8 Carrier Destination
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued To Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
O- Permission is hereby granted to dispose of the human remains described abov as igdicated.
Date October 15, 2013 Registrar of Vital Statistics �` �/
Issued (signet e)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on:
z if i7 Date of Disposition to i13 Place of Disposition ` 4. '
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w (address)
W
co
X (section) � (lot number) (grave number)
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W' Name of Sexton or Person in Charge of Premises ri�''t/)`_ ��/'11
(please print) �"
Si nature4 Title CP O(L
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(over)
DOH-1555 (02/2004)