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Jarvis Sr., Ronald Lee NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Ronald Lee Jarvis Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 05/01/2023 80 Years War or Dates 1961-1961 Place of Death Hospital,Institution or W City,Town or Village Kingsbury Town Street Address 305 Queens Drive Apt.F,Kingsbury Town,New York 12839 p Manner of Death ❑X Natural Cause Accident El Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title G Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Kingsbury District Number Register Number City,Town or Village 5762 9 HBurial Date Cemetery,Crematory or Facility Name 05/04/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date • Place Removed and/or and/or Held H Hold Address 0 n. Date Point of (/) Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above 2 Address CC ILLI O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/03/2023 Registrar of Vital Statistics Cynthia Bardin(ECectronicalTy Signed) (signature) District Number 5762 Place Town Of Kingsbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition .Tjy 173 Place of Disposition W 2 (address) W CC CC /section/ t (lot number) (grave number) S Name of Sexton or Person in Charge of Premises �-- it (please print/ IL Signature / Title !e'�mWfi DOH-1555(o7/18)p t of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#