Olsen, George NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
George R. Olsen Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 14, 2013 79 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death u Natural Cause Accident E Homicide Suicide Undetermined n Pending
Circumstances Investigation
O Medical Certifier Name Title
Suzanne Rayeski
Address
100 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 L/ <'o
❑Burial Date Cemetery or Crematory
❑Entombment November 15, 2013 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
Hold
O Date Point of
NIT Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
Address
re
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l //(gj Registrar of Vital Statistics ✓�^
natuec)e/
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:
�Z �► C.w �.
Date of Disposition 111t�i9 Place of Disposition ,ice
(address)
N
fY O (section) dilgt n mber) ("� (grave number)
Name of Sexton or Person in harge of P emises +A .]tr t
Z (pie print)
IL
Signature Title MEOW
(over)
DOH-1555(02/2004)