Olden, Wanda it
NEW YORK STATE DEPARTMENT OF HEALTH °i 276
Vital Records Section ,. Burial - Transit Permit
Name First Middle Last Sex
Wanda P. Olden Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/27/2011 75 years War or Dates
Place of Death Hospital, Institution or
ifi City, Towsili =a,;XX Glens Falls Street Address Glens Falls Hospital
0 Manner of Death r� b ,tural Cause El Accident 0 Homicide El Suicide �Undetermined Pending
W. Circumstances Investigation
CA
tu Medical Certifier Name Title
Nancy f) Carney M. D.
Address
Warrensburg Health Center Warrensburg, NY
Death Certificate Filed District Number Register Number
City, Tow Will XX Glens Falls 5601 199
'>€❑Burial Date Cemetery or Crematory
❑Entombment 04/28/2011 Pine View Cemetery
Address
`!4 Qyemation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address
ht Hold
0
0 Date Point of
E`Z`0 Transportation Shipment
C3 by Common Destination
iiip Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ir
tt
r` Permission is hereby granted to dispose of the human re ins des ribed ab e as indica d.
Mil Date Issued 04/28/2011 Registrar of Vital Statistics 67� s Rill; (signature)
ni District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ta Date of Disposition 9/n I J/ Place of Disposition ,4 c f d r we-
(address)
In
O.
CC (section) (lot lumber) . (grave number)
Name of Sexton orq Person in C rge of Premises ih f }aCir ehN
2 // (pl ase print)
Signature ( li— Title CU:ii14-1oi,
(over)
DOH-1555 (02/2004)