Hagadorn, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert T. Hagadorn Male
Date of Death Age If Veteran of U.S. Armed Forces,
09 / 27 / 2018 80 War or Dates N/A
}= Place of Death Hospital, Institution or
aZ City, Town or Village Stillwater Street Address 111 Brickhouse Road
Manner of Death®Natural Cause 0 Accident 0 Homicide �Suicide �Undetermined �Pending
0.
Circumstances Investigation
ul Medical Certifier Name Title
Carl Sgambati MD
Address
2nd Floor, 3050 NY-50, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City,Town or Village Stillwater
Burial Date Cemetery or Crematory
10 / 05 / 2018 Pine View Crematory
! <0Entombment Address
ii Cremation Queensbury, NY
Date Place Removed
1❑Removal and/or Held
and/or Address
Hold
9 Date Point of
Q Transportation Shipment
by Common Destination
Carrier
in<'Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
Al 402 Maple Ave. , Saratoga Sp. , NY 12866
Mi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
Ili
fii Permission is hereby granted to dispose of the human rem i s descr' ed above a dicated.
iiia
Date Issued /0-,2-02O/Registrar of Vital Statistics , 2 �
(si ture)
District Number //54 7 Place Stillwater , New York
t-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w
JAI Date of Disposition ;VS It7 Place of Disposition c;k , y;cm, (•,re,Acs4ory
ILI
(address)
CO
IICr (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 31, ,%ne,) S49n ri fe.5
z (please print) •
Signature .40,7!�f... Title LCtmq+G f
(over)
DOH-1555 (02/2004)