Oliva, Vivian M I
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Vivian M.Olivo Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/11/2022 100 Years War or Dates
1— Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 22 Twicwood Lane,Queensbury Town,New York 12804
111
O Manner of Death ❑X Natural Cause Accident El Homicide Suicide Undetermined Pending
IJJ
0 Circumstances Investigation
W Medical Certifier Name Title
0 Sean Campanie NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 172
Burial Date Cemetery,Crematory or Facility Name
e 11/18/2022 Pine View Crematory Entombment —
_
Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
U) Transportation
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
S Address
Ct
O▪. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/14/2022 Registrar of Vital Statistics Caroliinexldegard Bar6er(Ekctronicali:y Signe)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition l4"'9 BGZZ Place of Disposition ; 1114-10
W (address)
W
CC CC (section) (lot nu ber) (grave number)
8 Name of Sexton or Person in Charge of Premises I rg/ij1U',5=>
(please print)
W Signature r 1//
Title ()et,--e t'-
DOH-1555(o7/1.8)p t of 2
7
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#