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Olsen, Karl • P 1 NEW YORK STATE DEPARTMENT OF HEALTH - -It140 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Karl Milton Olsen Male Date of Death Age If Veteran of U.S. Armed Forces, 12/04/2013 76 years War or Dates 1-- Place of Death Hospital, Institution or City, -51PXOOPIX\AMM Saratoga Springs Street Address Saratoga Hospital Manner of Death©Natural Cause ElAccident 0 Homicide 0 Suicide E Undetermined Pending Circumstances Investigation 1U Medical Certifier Name Title 0 Theodores Laddis M. D. Address • • 6 Care Ln Saratoga Springs, Ny 12866 Death Certificate Filed District Number Register Number . City, -403eympr} Saratoga Springs 4501 501 • 2 ElBurial Date Cemetery or Crematory 12/06/2013 Pine View Cemetery ii ❑Entombment Address . ,,]Cremation Queensbury N Y . Date Place Removed Z Removal and/or Held 2❑and/or li,. Address U) Hold O Date Point of tZ Transportation Shipment G by Common Destination Carrier • Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Riii Permit Issued to Registration Number Name of Funeral Home Compassionate Care, Inc. 00364 Address 402 Maple Avenue, Saratoga Springs, N Y 12866 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address is !L Permission is hereby granted to dispose of the human re s ;V:Itive Indic d. Date Issued 12/06/2013 Registrar of Vital Statistics (signature) District Number 4501 Place Saratoga Springs '' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ILI Date of Disposition (1-11-i3 Place of Disposition Z,U , (,r.'K,ttr — (address) Ili U LC (section) 4, of number)- (grave number) Name of Sexton or Pers in Charge of remises St " •Onwi 2 (please print) rL . • Signature -, Title CVilina (over) DOH-1555 (02/2004)