Hagglund, Robert NEW YORK STATE DEPARTMENT OF HEALTH '! # -(L C
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert G. Hagglund Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 7,2012 63 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 2191 Canada Street Apt 15
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Gary Scidmore,Coroner
Address
Lake George,NY
Death Certificate Filed District Number �bs Register Number?
City, Town or Village Lake George,NY
❑Burial Date Cemetery or Crematory
❑Entombment September 12,2012 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
O and/or Address
F' Hold
N
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name 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 described above as indicated.
Date Issued 9 - it -d-_O1 ?Registrar of Vital Statistics G( , ,�
(signature)
District Number (a S ' Place Lake George,NY
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition Place of Disposition
W (address)
N
rt (section) (lot number
• Name of Sexton or Person in Charge of Premises ) (grave number)
W (please print)
Signature Title
(over)
DOH-1555(02/2004)