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Olsenwik, John NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John Olsenwik Male Date of Death Age If Veteran of U.S.Armed Forces, 05/24/2021 88 Years War or Dates Korean ZPlace of Death Hospital,Institution or W City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare p Manner of Death © Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending III Circumstances Investigation 0 Medical Certifier Name Title Leonard Gelman MD Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed District Number Register Number City,Town or Village Argyle 5750 37 ElBurial Date Cemetery,Crematory or Facility Name 05/25/2021 Pine View Crematory Ej Entombment Address 0 Cremation Queensbury Town,New York ❑Donation ZZ Removal Date Place Removed and/or and/or Held F- N Hold Address 0 a Date Point of co ❑Transportation aby Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address CC w n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/25/2021 Registrar of Vital Statistics Sheley9Kckenaon(Electronically Signed) (signature) District Number 5750 Place Argyle, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— lL_ W Date of Disposition ��Z4 I Z{ Place of Disposition -.z—..... 2 (address) W U) CC (section) 4 (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premis p�1 I1.� ��niti `Z //�� (plebse print) �y,� Signature L✓' Title C DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01.4 81 4 i 3 Receipt f 1 Human remains of .._ delivered on , 20 I 11 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# { 1 ;j