Peterson, Walter Funeral Dirictor �bDC/s
,p T,/- / !44J Case Number
Name - /�----�-- ------__— ._.
Date of Cremation
Time Cremation Started
Time Cremation Completed�''`ry �Type of of container
Remarks
PINE CREMATORIUM, INC.
PINS Quaker Road, Glens Falls, NY 12801
CREMATORIUM,INC. Phone (518) 798-4726 or if no answer 792-1114
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine Crematorium, Inc. in accordance with and subject to its Rules and
Regulations to cremate the remains of:
Walter Peterson MaiA
(NAME) (SEX)
23 Baxter St Rutland Vermont 05701
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 1st —day of Marcy 19_ 22
at Rutland, Vermont
(ADDRESS)
(PLACE)
i
Name and address of nearest living relative or name of person authorizing cremation:
Mrs Harry (Marion) Buckminster 45 Overland St Manchester Cann_ n6n4n
(NAME)
(ADDRESS)
Relationship to the deceased Si ster
Name of funeral home Aldous Funeral Home
IMPORTANT: I represent that to the best of my knowledge, the deceased has or as no pacemaker in�&or
her body. (CIRCLE ONE).
I certify that I have the full power and authorization to arrange for the cremation of the remains and to direct the
disposition of the cremated remains,that any personal possessions have either been removed or may be destroyed,
and agree to protect, defend and save harmless Pine Crematorium, Inc. from any and all claims and demands for
loss or damages which may be made against them by reason of, or connected with,the cremation of said remains as
directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
(WITNESS) (SIGNATURE OF RELATIVE OR LEGAL REP.)
(ADDRESS) (ADDRESS)
Signed on this date
DISPOSITION OF CREMATED REMAINS
hereby direct Pine Crematorium, Inc. to dispose of the cremated remains as follows:
Mail to Aldous Funeral Home 44 North Main St. Rutland, Vermont 05701
Other arrangements - please specify:
i
If pulverization of cremated remains is requested, check here:
State of Vermont
Examiner' s Permit to Cremate a Dead Human Body
Name, Walter Peterson
Address 23 taxter St Rutland, Vermont 05701
Date of Death 3/1/88
Place of Death Rutland, Vermont
Permission to Cremate tis Body At
Pine View Crematory, Glens Falls, NY 12801
.( Name of Crematory) -
?Requested BY, Aldous Funeral Home
( Name of Funeral Director)
Vt. State F>D> # 19
Being Sufficiently informed as to the causes and
circumstances of the death of the,•. aboved described +�
decedent, Permission is hereby granted to cremate
the body as requested.
("'t
date --� �� signed
Ex er s Add ess F
Aldous Funeral Service
44 No. Main Street
Rutland, Vt. 05701 773 6252
MAILGRAM SERVICE CENTER
MIDDLETOWN, VA. 22645
02AM _ •
1-010849AO62 03/02/88 ICS IPMMOZH MTN) WJRC
02041 MOORESTOWN NJ 03-02 0142P EST MOZG
JOHN BLY
ALDOUS FUNERAL HOME NORTH MAIN ST
RUTLAND VT 05701
4-016212SO62 03/02/88
ICS IPMMTZZ CSP
2036492756 FRB TDMT MANCHESTER-MC CT 9 03-02 0125P EST
ICS IPMMOZZ
MR JOHN BLY, FON 8027736252
ALDOUS FUNERAL HOME NORTH MAIN ST
RUTLAND VT 05701
THIS IS A CONFIRMATION rnPv nF A TFIFGRAM SFNT Tn vniI . 04
I AUTHORIZE THE CREMATION OF MY BROTHER, WALTER PETERSON.
MRS MARION BUCKMINSTER
1330 EST 04
13:45 EST 04
MGMCOMP 04
04
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