Hagstrand, Bruce NEW YORK STATE DEPARTMENT OF HEALTH L.
11
Vital Records Section Burial - Transit Permit
N Name First Middle Last Sex
Bruce S Hagstrand Male
• Date of Death Age If Veteran of U.S. Armed Forces,
December 18, 2015 60 War or Dates
Place of Death Hospital, Institution or
;,- City, Town or Village Glens Falls Street Address 5 Bacon Street
,o3 Manner of Death I XI Natural Cause n Accident [ I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Reeves Dr.
Address
3 Iron.ate Center,Glens Falls,NY 12801 _
r. Death Certificate Filed District Number Register Number
:. City, Town or Village Glens Falls 5601 609
❑Burial Date Cemetery or Crematory
❑Entombment December 21, 2015 Pine View Crematorium
Address
I1 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
0 and/or Address
E Hold
co
O Date Point of
LL N I I Transportation Shipment
a by Common Destination
Carrier
I (Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
✓ .A Permit Issued to Registration Number
r;.; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
° Address
r.0 53 Quaker Road, Queensbury, NY 12804
rName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
: Date Issued + Z I C 5 Registrar of Vital Statistics
Wes, ,,.,R
.▪ : (signature)
;, District Number 5601 Place Glens Falls, Al v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U Date of Disposition /2•Z2i1 Place of Disposition Pme v ,TO
t-eaai 6re_enary
W (address)
0
CC (section) (lot number) (grave number)
pName of Sexton r Person in Charge of Premises ,1.1;o-n 4..Ma-
W /// (please print)
Signature ��` Title Cco_h? f r
(over)
DOH-1555(02/2004)