Olsen, Henry . , 4 (03D
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Arthur t Sex
Henry Arthur Olsen Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/21/2013 76 years War or Dates 1963-1966
• Place of Death Hospital, Institution or
City, 1S rI T Xr) 115g Saratoga Springs Street Address Saratoga Hospital
Ili0 Manner of Death J Natural Cause 0 Accident ❑Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
Rodney Ying MD
Ayrtle Street Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
City, TISitficXrVAMg Saratoga Springs 4501 425
❑Burial Date Cemetery or Crematory
10/23/2013 Pineview Crematorium
❑Entombment Address
OCremation Oueensbury N Y
Date Place Removed
Z Removal and/or Held
3❑and/or Address
F_ Hold
O Date Point of
fk❑Transportation Shipment
O by Common Destination
B. Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
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
III
�` Permission is hereby granted to dispose of the human remai riled ab 'ndicate
Date Issued 10/23/2013 Registrar of Vital Statistics �'b>
(signature)
District Number 4501 Place Saratoga Springs
lI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2, f�
ILI Date of Disposition 10 / q j(3 Place of Disposition �,i•t ' ' � ���`
2 (address)
LU
w
tc (section) (lot umber) ( (grave number)
CI Name of Sexton or Person in Charge of Premises J
I► (pl ase print)
iii
Signature 46,_ �(�s Title CIMMRTOt
(over)
DOH-1555 (02/2004)