Olsen, Patricia NEW YORK STATE DEPARTMENT OF HEALTH c it 4 lS 1
Vital Records Section Burial - Transit Permit
nii Name First Middle Last Sex
Patricia Elenor Olsen female
Date of Death Age If Veteran of U.S. Armed Forces,
Oct. 1 4, 201 4 76 War or Dates
1:-' Place of Death Hospital, Institution or
Town of Hartford 30 Baker Rd (Granville)
i City, Town or Village Street Address
a Manner of Death uicr7 Natural Cause E Accident El Homicide 0 Suicide El Undetermined n Pending
Circumstances Investigation
ILI Medical Certifier Name Title
Q Darci Gaiotti—Grubbs MD
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
iiiig El Burial Date Cemetery or Crematory
10/17/14 Pine View Crematory
<; i;❑Entombment Address
Hi®Cremation 21 Quaker Rd Queensbury, NY 1 2804
Date Place Removed
f1 ❑Removal and/or Held
and/or Address
I Hold
CO
O Date Point of
tX
❑Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01 079
Address
82 Broadway Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
2
ILI
Permission is h reby granted to dispose of the human r ains descri a a• •ve as indicpte
Date Issued 0 £ Q i 1' i iL-
1I rJ
\1 \t-k Registrar of Vital Statistics
(signatur.
�A )
District Number 5`7 S`\ Place l r4- (d j".3 J ` r-ic
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
0h�to Date of Disposition folly Place of Disposition ,w, ,,, ,,"
2 (address)
111
CA
CC (section) (lot number) (grave number)
Name of Sexton or Person in Char a of Premises 6^h` S�iie
(phase print)
Signature 4..
Title ` n
(over)
DOH-1555 (02/2004)