Jarvis, Charles t 1
4 Val
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles William Jarvis Male
- Date of Death Age If Veteran of U.S.Armed Forces,
11/07/2018 94 Years War Or Dates 43-46
Place of Death Hospital, Institution or
5 City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
0 Manner of Death g Natural Cause D Accident El Homicide D Suicide Undetermined ri Pending
Circumstances Investigation
jj Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 158
0 Burial
Date Cemetery or Crematory
11/09/2018 Pine View Crematory
Entombment Address
`, ®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
'0 Date Point of
IA 0 Transportation Shipment
a by Common Destination
Carrier
[]Disinterment Date Cemetery Address
Q Renterment
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
iName of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
u= Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/09/2018 Registrar of Vital Statistics Caroline If Barber(ECectronica1tySigned)
(signature)
District Number 5657 Place Queensbury, New York -
I certify that the remains of the decedent identified above were disposed of in accordance withthis permit on:
W Date of Disposition iJ J1IIE Place of Disposition gu�— l r1,,.{o. -
$ (address)
trL
EC (section) (lot tuber) (grave number)
0 Name of Sexton or Person in Charge of Premises 4"'i � 3'''`'4'
z 4 (please int)
W' Signature Title 4mq/11-
(over)
DOH-1555(02/2004)