Jarvis, Jr. Francis ,�- 1
/00
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francis Arthur Jarvis Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/28/2018 65 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident Homicide Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Noelle Stevens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 53
❑Burial
Date Cemetery or Crematory
01/30/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
„�❑Removal and/or Held
—1 and/or
Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
04 Li Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
---11 Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/30/2018 Registrar of Vital Statistics Men a Curtis(ETctronica1TySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remainsof the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I'//3j hi Place of Disposition rnck �
(address)
141
(section) //(lot number) (grave number)
G�
Name of Sexton or Person in Charge of P mises r�> it
(pl ase print)
Signature Title 40.6thitryi,
(over)
DOH-1555 (02/2004)