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Olden, Jason A
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jason A.Olden . " Male Date of Death Age If Veteran of U.S.Armed Forces, 07/10/2023 38 Years War or Dates F Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address 2536 State Route 8, Johnsburg Town, New York 12843 WManner of Death ❑Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation G Medical Certifier Name Title Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 25 Burial Date Cemetery,Crematory or Facility Name 07/13/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of f!)ETransportation by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address 1—'Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above a Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/12/2023 Registrar of Vital Statistics Jean.74Comstock(ECectronicaccySigned) (signature) District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition 7 f l3)23 Place of Disposition (� 2 (address) W CC fn (section) pat number) (grave number) Name of Sexton or Person in Charge of Premis Z (Pease print) W Signature Title ( ' CW DOH-1555(07/18)p i of 2 to kJ 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#