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Gagnon, Bill J NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Bill J.Gagnon Male Date of Death Age If Veteran of U.S.Armed Forces, 10/01/2023 70 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc IJJ• Manner of Death Ei Natural Cause Accident ❑Homicide Suicide Undetermined Pending ✓ Circumstances Investigation W Medical Certifier Name Title CI Rick Teetz MD Address 131 Lawrence St,Saratoga Springs,New York 12866 Death Certificate Filed City Of Saratoga Springs District Number Register Number City,Town or Village 4501 562 Burial Date Cemetery,Crematory or Facility Name 10/02/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held H Hold Address N 0 a Date Point of to Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address El 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 F- Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/02/2023 Registrar of Vital Statistics Dillon Moran(Electronically Signed) (signature) District Number 4501 Place City Of Saratoga Springs I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition /o 13173 Place of Disposition IOE-v c(L, (1—_InA re,mei ui 2 (address) W CO Lt (section) l II; r (lot nu t r) (grave number) O Name of Sexton or Person in Charge of Premises ' 1nr, ^^`h Z Z 7 (please print) W Signature �' Title 714.12 DOH-1555(o7/18)p 1 of 2 1. x33 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#