Olsen, Marlene iJt/1b71017 06:19 5183773446 t ?.LIGHTS FUNERAL HOME PAGE 01/03
1 630
NEW YORK STATE DEPARTMENT OF HEALTH
• Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
CLAIRE OLSEN
FEMALE
s Date cif DeaMARr•RN Age' If Veteran of U.S.Armed Forces,
}' n7/06/201.7 79 War or Dates NONE
Place of Death Hospital, Institution or
C. ,Town or Village _ ALBANY . ._ Street Address • ALBANY MEDICAL CENTER
w` Manner of Death f Natural Cause 0 Accident El Homicide 0Suicide Q Undetermined ri Pending
_ Circumstances investigation
`°' Medical Certifier Name Title
_ .GARY' VOLKELL MD _ .
Address
43 NEW SCOTLAND AVE., ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,ToWri or Village ALBANY _ _ 101
't■Burial Date Cemetery or Crematory
f'`` 071].212017 PINE VIEW CREMATORIUM
f,< nfombmerit Address
,
;, : Cremation OUR U11X... NEW PORK
Y u Place Removed
�� Date
Removal and/or Held '
and/or Address
-,n Hold
Date Point of
Q Transportation Shi ment .
by Common Destination
Carrier
• �; Date• Cemetery Address
;_Lj Disinterment
Date - Cemetery Address
'"f 0 Reinterment
o
Permit Issued to - Registration Number
Name of Funeral Home REGAN DENNY STAFFORD FCINERAL, ROE 01443
Address
? 53 QUAKER RD., QUEENSBURY, NY 12804
u y
• Z1 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 hu mains described above as indicated. .
.:,::•,!: Date issued 07/0/201. ':. Registrar of Vital Statist
(ry
�h� gnature)
:t;.v.5
District Number 1 Oi .f, place ALBANY POLICE DEPARTMENT, ALBANY, NY _.
, � ...
rids 1.
a I certify that the remains of tie decedent identified above were disposed of in accordance with this permit on:
°a Date of Disposition: 71 131 I') Place of Disposition
ntVd�rr J �c
(section} —� pot number)
. (grave number)
� '
Name of Sexton or Person �4
in Charge. Premises e
Signature Title jek 4i it
(over)