Olson, Rosemarie Ili # 3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rosemarie Lucille Olson Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/19/2018 79 Years War or Dates
t- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
W®- Manner of Death X❑Natural Cause ❑Accident ❑Homicide El Suicide ri❑Undetermined El❑Pending
Circumstances Investigation
ui Medical Certifier Name Title
0 Dean Reali DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 34
❑Burial Date Cemetery or Crematory
01/22/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-:h Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
XAddress
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/22/2018 Registrar of Vital Statistics gp6ertACurtis(E(ectronicallySigned)
(signature)
District Number 5601 Place Glens Falls, New York
II certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Kt Date of Disposition rI/1.3j1g Place of Disposition 4x4L 44r4121019.04.1
2 (address)
Ill
N
Q; (section) (lot number (grave number)
h
Z Name of Sexton or Person in Charge of Pre ises
(Please lt.- �.t�
ase print)
Iii
Signature 41 . r Title l'R mft1 L
(over)
DOH-1555 (02/2004)