Hansen, Ole 1
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NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
' Name First Middle Last Sex
='', Ole Boeiskov Hansen Male
!' , Date of Death Age If Veteran of U.S. Armed Forces,
°= 04/17/2018 77 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
? Manner of Death 0 Natural Cause Ei Accident ❑Homicide El Suicide 0Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
to
Frances Bollinger MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 193
;. ❑Burial Date Cemetery or Crematory
04/19/2018 Pine View Cematorium
❑Entombment Address
®Cremation Queensbury, New York
tA Date Place Removed
't. Removal
� and/or Held
and/or Address
Hold
, Date Point of
..F. El Transportation Shipment
u��w1
by Common Destination
a Carrier
*V,
El Disinterment Date Cemetery Address
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
k Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
°lk Permission is hereby granted to dispose of the human remains described above as indicated.
if
Date Issued 04/18/2018 Registrar of Vital Statistics pbert A Curtis(Efectronica1Cy Signed)
(signature)
x District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
°tE Date of Disposition q/Pii3 Place of Disposition A. C
(address)
(section) number (grave number)
1 Name of Sexton or Person in Charge of Premises . t..µ{t
Signature (P/ print)Title lei F✓r2
(over)
DOH-1555(02/2004)