Gagnon, Richard NEW YORK STATE DEPARTMENT OF�EAL�H Burial - Transit Y@rtYtlt
Vital Records Section
k. Name First Middle Last Sex
Richard Henry Gagnon Male
P,;' Date of Death Age If Veteran of U.S. Armed Forces,
12/11/2016 68 War or Dates Vietnam
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
. Manner of Death m.] Natural Cause 0 Accident El Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
y Medical Certifier Name � A_ Title
MARUVIN DADIDOWITZ, /`�
: ! Address
100 PARK ST Glens Falls, NY 12801
Death Certificate Filed District Number Re i ter Number
City, Town or Village g �3
0 Burial Date C etery or C mato � —
12/06/2016 (( //--e/1 c/d!/c/` --/
0 Entombment Address
,,! ;®Cremation a/� � �/�� ��i4 VDate 000 Place Removed I
,` 0 Removal and/or Held
and/or Address
Hold
II
Date Point of
0 Transportation Shipment
by Common Destination
-41 Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:, Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
:AA 9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
= Address
_ Permission is hereb granted to dispose of the humaktemains escribed-above as i • . d.
Date Issued Registrar of Vital St tistics W—i.c\`�? J
( gnature)
District Number i Place vQ 7
I certify that the remains of the decedent identified above were disposed of in accordan with this permit on:
Iry—
Date of Disposition IZ(IS'f(L Place of Disposition ?a,0.1,./ ofiosU,
(address)
(section) ��Plot number) (grave number)
1; j I�f
.; Name of Sexton or Person in Charge of Premises h+►l�'
,� ( ease print)
,;j- Signature a ,-4tJ11 Title C IZtIh -
(over)
DOH-1555 (02/2004)