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Olsen, Henry NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Henry Daniel Olson Male Date of Death Age Tifteran of U.S.Armed Forces, 01/01/2020 22 Years r or Dates Place of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address 16 Heinrick Street,Queensbury Town,New York 12804 Manner of Death ❑X Natural Cause Accident Homicide ❑Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Timothy Murphy Coroner Address 52 HAVILAND AVE,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 3 ©Burial Date Cemetery,Crematory or Factlity Name 01/06/2020 Pine View Cemetery Entombment Address ❑Cremation Queensbury,New York ❑Donation z Removal Date Place Removed F and/or and/or Held Hold Address V) ❑Transportation Date Point of 5 by Common Shipment Carrier Destination Disinterment Date Cemetery Address EIReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/03/2020 Registrar of Vital Statistics CaroCtnexfgarde Bader(EkctronicalT Signed!/ (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition - .aURp Place of Disposition W a (ad ess) W / yIr (section) (lot number) (grave number) O Name of Sexton or Person in Charge of Premises (Please print) Z YJ Signature Titl DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) 010361 1O361 Receipt r Human remains of i' !' i delivered oir'�is , 20 n ne View Ce eery Representing the funeral home named on burial permit Official Funeral.Directors Reg.or License# — Olson NAME Henry Daniel Olson Age: 22 Lot Owner: Diana C. Ettinger Lot# 84H Mohican Grave# 1 Case: Concrete Died: Interred: 1 /1 /2020 1 /6/2020 Funeral Home: Scott & Barbieri Funeral Home Cemetery: Pine View Cemetery