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Hagadom Jr. Kevin D
it NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kevin D Hagadorn Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 01/24/2021 40 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Wilton Town Street Address 4 Raceview Drive,Wilton Town,New York 12831 ILI p Manner of Death ❑Natural Cause El Accident ❑Homicide ElSuicide Undetermined ©Pending W U Circumstances Investigation W Medical Certifier Name Title 0 David DeCelle Coroner Address 40 McMaster Street,Ballston Spa,New York 12020 Death Certificate Filed District Number Register Number City,Town or Village Gansevoort 4569 6 Burial Date Cemetery,Crematory or Facility Name 02/01/2021 Pineview Crematory ElEntombment Address lCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of N j Transportation Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address Q W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/26/2021 Registrar of Vital Statistics Susan Baldwin(Electronically Signed) (signature) District Number 4569 Place Gansevoort, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Ii— Z Date of Disposition Z ► Z I Place of Disposition 1ti t� (address) W N CC (section) (tot number) (grave number) II�J • Name of Sexton or Person in Charge of Pre? s ty �'"� Z (Neese print) f W Si nature Title 4 f` � g DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 .4 4 9 c Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#