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Hagadorn, Jean M. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jean M.Hagadorn Female Date of Death Age If Veteran of U.S.Armed Forces, 11/27/2020 87 Years War or Dates i` Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital Ill p Manner of Death © Natural Cause I:IAccident ❑Homicide 0 Suicide 0 Undetermined ❑Pending 11.1 Circumstances Investigation 2. Medical Certifier Name Title a Timothy Waters DO Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 606 ©Burial Date Cemetery,Crematory or Facility Name 11/30/2020 Pine View Cemetery ❑Entombment Address ElCremation Queensbury Town,New York ElDonation Removal Date Place Removed and/or and/or Held H N Hold Address 0 d. Date Point of Cl) ❑Transportation ,0 by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/30/2020 Registrar of Vital Statistics John Paul Franck(Electronically Signed) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IF- Z Date of Disposition 1 1 /3 0/202 0 Place of Disposition 21 Quaker Rd. Queensbury, NY 12804 W (address) W Huron 1 3C 2 NLE (sectio (lot number) (grave number) 0 Name of Sexton or rson in Charge of Premises _©A t1fE L `�,r—j Z (p a print) W Signature &Ail /L - -ed_I- -- Title (1,44/tift/ ALL412‘17' DOH-1555(07/18)p 1 of 2 Public Health Law Sec.4145(2b) U 12 8 2 3 Receipt , Human remains of.. ' '} r delivered on l` ) , 20_'_ ' d/. 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# HAGADORN NAME Jean M. Hagadorn Age: 87 Lot Owner: Karl & Jean Hagadorn Lot# Huron 13-C Grave# 2 Case: Concrete Died: Interred: 1 1 /27/2020 1 1 /30/2020 Funeral Home: Brewer Funeral HOme Inc. Cemetery: Pine View