Olden, Royce Walter ti # Si il
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Male
Royce Walter Olden
Date of Death Age If Veteran of U.S.Armed Forces,
07/13/2022 64 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Hudson Falls Village Street Address 29 Main Street 6, Hudson Falls Village, New York 12839
0 Manner of Death 0 Natural Cause ❑Accident Homicide Suicide Undetermined Pending
11JCircumstances Investigation
U Title
W Medical Certifier Name
0 David Foote MD
Address
340A Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 36
Burial Date Cemetery,Crematory or Facility Name
07/19/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal. Date Place Removed
and/or and/or Held
F Hold Address
N
d -
Date Point of
N Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/19/2022 Registrar of Vital Statistics Cynthia A(Bardin(ECectronicallySigned)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition '7/10 I Z2 Place of DispositionFIJI—
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2 (address)
W
N
CC (section) (lot number (grave number)
8 Name of Sexton or Person in Charge o ises Nr L tr
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W g Si nature W Title L p'44113
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DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
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Pine View Cemetery Representing the funeral home name cl on bitrigl permit
Official Funeral Directors Reg.or License#