D'Agostino, Harry John Jr. MD L3
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Harry John D'Agostino Jr MD Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/08/2022 65 Years War or Dates
F.. Place of Death Hospital,Institution or
WCity,Town or Village Bolton Town Street Address 66 Fish Point Road,Bolton Town,New York 12824
CI Manner of Death ❑X Natural Cause Accident Homicide Suicide ElUndetermined El Pending
W Circumstances Investigation
V
W Medical Certifier Name Title
G Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Bolton District Number Register Number
City,Town or Village 5650 5
Burial Date Cemetery,Crematory or Facility Name
08/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
p. Hold Address
N
O
d Date Point of
N Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/09/2022 Registrar of Vital Statistics Jodi Petteys(ECectronicalry Signed)
(signature)
District Number 5650 Place Town Of Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 121101 tZ Place of Disposition 17,
2 (address)
W
CC N (section) /71 ,Jlot number/ (grave number)
8 Name of Sexton or Person in Charge of Premises
Z / (Awe print)
W Signature Title if•nq 1z<
DOH-1555(o7/1B)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of _ + delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License# `,�