Olsen, Kari 9451
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kari Olsen I Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/25/2020 87 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Yorktown Town Street Address North Westchester Restorative Therapy And Nursing Center
C3 Manner of Death ❑c Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
C3 Josmi Joseph MID
Address
3550 Lexington Ave,Yorktown Town,New York 10547
Death Certificate Filed District Number Register Number
City,Town or Village Yorktown Heights 5968 88
❑Burial Date Cemetery,Crematory or Facility Name
05/01/2020 Pine View Cemetery and Crematorium
Entombment Address
XJ Cremation Queensbury,New York
Donation
zRemoval Date Place Removed
and/or and/or Held
~N Hold Address
O
d Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Clark Funeral Home Inc 100340
Address
2104 Sawmill River Rd,Yorktown Heights,New York 10598
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
Address
Q
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/28/2020 Registrar of Vital Statistics D--LQ—t(Ekrtronir-YSrgne4
(signature)
District Number 5968 Place Yorktown Heights, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H Z Date of Disposition 7b Place of Disposition Fr—IL r-�—
(address/
W
N
a: (section) (lot number/ (grave number)
GName of Sexton or Person in Charge of Prem' es r`t
Z (plea print)
W Signature Title '''t
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) '- -
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on buri#permit
Official Funeral Directors Reg.or License#