Gardner, Kathryn v�urt v �cee�2:s u�t,.
rmE VIEW CEMCTERY and CREMATORIUM
QUAKER ROAD. QUEE 79�RY, NEW YORK 12801
(518) 793-9777
Funeral Dirictor �,--
Case No. ��'
tivnA 22 C
UALe of Cremation -J /
I'intn Cremation Started a�
1'i.me Crert-ition Completed
type of Ccmtainer KK
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
KATHRYN GARDNER FEMALE
Name Sex
BALLARD ROAD WILTON N.Y. 12866
Street City) State
Zip Code
who died on 7-19-90 day of 19
at WILTON DEVELOPMENTAL CENTER WILTON,N.Y.
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
NER P.O. BOX 499,LAKE LUZERNE,N.Y. 12846
Name Address
Relationship to the deceased BROTHER
Name of the funeral home BREWER FUNERAL HOME,INC.
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 View Crematorium, 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 Rela ive or Legal Rep.
Address)
Address
Signed on this date
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name First j Middle Last
Sex
Date of Death ; Age ff Veteran of U.S.Armed Forces,
War or Dates
Place of Death' ?/ Hospital, Institution or
Villag City.Town or e m Street Address
t Cause of Death
Medical Certifier" Titl
Address
Death Ceitificate'riled• istrid Number /l�m r Num
City,Town or Village
Date Comet r
Crematory,-Burial
» 7�- �?�-
ER
Cremation
' Address
Date
O ❑ Removal l and/or Held
- and/or Hold£YA—d'r'ess»-...:�»,,,»-N
94 Date :; Point of
ux []Transportation by t Shipment
GCommon Carriernation.�....:.:......:.»...w.,..,xN.�.._M,.,.k...,......:,..�...,....,.w:,..:::..».w.:..,..:.,,,.»»:..».:,.:..:.,::::N:,,..,..,»..:::x.:..»,.x.�.,..».N:.w�...��..�........:.::.��.
❑ 'Disinterments H A»< Date w� f Cemetery Address - M
❑ Reinterment Date Cemetery Address
i
Permit Issued to Registration Number
Name of Funeral Fir A Q 4 nZ Z
Address
....
} Name of Funet ir'm Making Disposition �Whom�:
Remains are Shipped,9 Other than Above
ress,v..:.,.,»»».�:::.v....-�,,,».,.,�,,.�,�..,..,.,
..........
Permission is hereby granted to dispose of the human remains described above as indicated.
1
>'k Date Issued `7 �0 C Registrar of Vital Statistics �J/
(ire)
f District Number 15Z Place /-
I certify that the remains of the decedent identified above were disposed of in a000rdance with this permit on:
Date of Disposition O Place of Disposition /"//✓ /�/.�� C 1P�/1?r9 701 t / "
(address)
ut:
'oe /
(section) (lot number) (grave number)
Name of Sexton o Person in arge of Premis
Vease prkt)
Signature 0 Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)