Cheney, Donald G Funeral Dirictor
Names ���/ �/ Case NumberJ�� -
Date of Cremation '",el7
Time Cremation Started o� 3 - �- -�—f-----------..
6 11/ /17
Time Cremation Completed_-__
Type of container 9A/f
Remarks
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Sate of Vermont
Examiner' s Permit to Cremate a Dead Human Body
Name, .w��t11 ._ChQn�
Address 65 Wood Aye. Rti. and.-Vte.05701
Date of Death 4/6/88
Place of Death 65 Wood Ave, Rutland, Vt. 05701 _v
Permission to Cremate ti. . Body At :
Pine View Crematory Glens Fa115, NY 12801
( Name of Crematory !
'Reauested BY, Aldous Funeyral Home 44 N Maims St. Rutland
Name of Funeral Director) ~�!
Vt . State F>L)> # 19
Being SufficiLntl,Y -informed as to the causes- and
circumstances c-f the death of the aboved described
decedent. FermiSsion is hereby granted to cremate
the body as reauested.
date ` �- �_ _ signed _
Examiner' Address `t
Aldous Funeral Service
44 No. Main Street
Rutland, Vt_ 05701 773 62E2
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PINE _ PINE CREMATORIUM, INC.
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:
Donald r.- chene:v Male
(NAME)
(SEX)
65 Wood Ave. Rutland, Vermont 05701
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 6th day of April 19 88
at 65 Wood Ave. Rutland, Vermont 05701
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
sus;- 01'Ane;r 65 Wood Ave Rutland Vermont 05701
(NAME)
(ADDRESS)
Relationship to the deceased —Wife
Name of funeral home Aldous Funeral Home
IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his 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 jwhether such
_clai mands are, or are not, wholly groundless, false or fraudulent.
(WITNESS)
(SIGNATURE OF RELATIVE OR LEf AL REP.)
(ADDRESS) (ADDRESS)
Signed on this date 4/6/88
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine Crematorium, Inc. to dispose of the cremated remains as follows:
Mail to __Aldo us Funeral Home, 44 North Main St Rutland, Vermont 05701
We need them by Friday if at all possible
Other arrangements- please specify:
If pulverization of cremated remains is requested, check here: