Jacobsen, Olaf NEW YORK STATE DEPARTMENTJF,HEALTHr.-
Vital Records Section Burial - Transit Permit
<< Name First Middle Last Sex
Olaf M. Jacobsen Male
Date of Death Age If Veteran of U.S. Armed Forces,
12 / 08 / 2015 83 War or Dates
-- Place of Death Hospital, Institution or Saratoga Hospital
Z Cityliti , Town or Village Saratoga Springs Street Address
p Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined Pending
Circumstances Investigation
49 Medical Certifier Name Title
Elizabeth A. Valentine MD
Address
Mc 211 Church St. , Saratoga Springs, NY 12866
Ai Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs r Kc '
kg in Burial Date Cemetery or urematory
iil 12 / 09I 2015 Pine View Crematory
1BEntombment Address
Cremation 21 Quaker Road, Queensbury, NY
Date Place Removed
4❑Removal and/or Held
and/or Address
Hold
Date Point of
piri Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
illi
l '>Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
`•. Name of Funeral Home Compassionate Funeral Care, Inc 00364
iiiiMi Address
402 Maple Ave., Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
, Address
Cr
ll
Permission is her by ranted to dispose of the human re • sc ' ed aggv indicat d.
.�
<: Date lssued ,Z Q '� Registrar of Vital Statistics I"
(signature)
District Number L SZ, Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /�
la Date of Disposition rt lill is Place of Disposition ,�,.(�f. Gioncio.....
ILA
(address)
0
CC (section) 1 (lot number) rs (grave number)
CZ
CI Name of Sexton or Person in Charg of Premises tantl}
= (please print) .
Signature A Title (11661491
(over)
DOH-1555 (02/2004)