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Olson, George w.
4 tZ NEW YORK STATE DEPARTMENT OF HEALTH ` — Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex George W Olson Male Date of Death Age If Veteran of U.S.Armed Forces, 10/23/2021 59 Years War or Dates 1980-84 �.. Place of Death Hospital,Institution or W City,Town or Village Hadley Town Street Address 3 Adirondack Road,Hadley Town,New York 12835 W Manner of Death ©Natural Cause El Accident El Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Danielle Jourdan Coroner Address 4205 Route 50,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 21 IDBurial Date Cemetery,Crematory or Facility Name 10/27/2021 Pineview Crematory El Entombment Address ElCremation Queensbury Town,New York ElDonation O Removal Date Place Removed and/or and/or Held N Hold Address 0 IlL Date Point of U) 11 Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above a Address Q W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/26/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: //f' Z Date of Disposition /0'1IO1j Place of Disposition [atUfr.► W 2 (address) W N CC (section) /� (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises /'�0 (plea print) W Signature - Title � �y`L DOH-1555(07/18)p t of 2 - €31_ 5' Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 • Pine View Cemetery Representing tffie funeral home named on burial permit Official Funeral Directors Reg.or License#