Casselman, Patricia jot un o/
riNE VIEW CEMCTERY ,ind CREMATORIUM
QUAKER ROAD. QUEEE'798UPY, NEW YORK 12801
-4726
(518) 79:3-9777
Funeral Dirictor �CJr M
Case No. ; 9/)
UnLe of Cremation _
'1'inM Cremation Started frSS�
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'1'i.me Cremation Completed i '
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY41-7*2
do
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:
(Name)
(Sex)
gun`�`�i. r�a,14� .� ,U. P/�,3�treet (Cit
Y� (S te) (Zi Code)
who died on jD°_`� day of AU9 - 19e,
at ��zig7PW011.4A) A
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased filX9
Name of the funeral home ,//gi. Ag-/ly,, .J o c �/G.
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 Relative or Legal Rep.)
(Address) (Address)
Signed on this date ,e iy
0
AUG 31 '90 09:24AM 707-942 5775 F.1!1
MART'HA CASSELMAN
Literary Agent
Box 342, Calistoga, CA 94515-0342 * Phone: 707 942.4341 • FAX:7457%?s l
4;! aW
TAM Smitty Marvin, courtesy Mr. Gordon Davis
Via FAX 1 518 873-2038
This is to authorize the cremation Of Mrs . Patricia W.
Casselman, my mother, who died this morning, August 30 ,
1990 , in Elizabethtown, N. Y.
Please cal me at my home number 707 942-5464 , if I
can be o"further ervice.
Thank yo
8/30/90
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name A
Middle
Last
Sex
C
Date of Death Age /� If Veteran of U.S. med Forces,
..... ......
C War or Dates
..............:......:::::::::::::...::::::.... .......:::::::::._::::::,:,::::::::;:::::,,:: ::.:............... ........................................................................
Z Place Bath Hospital, Institution r //
City ow or illage 7.t' � �cJ Street Address � j ,� /Yey..../ ......
...c.....s....:::::..:::::::::..... :...... ........
-----:------: ......:::::.:......::::....::::::.
'use of ath
Medical Certifier rue Title
EC �P s
s�� S i'//D
Address
L i9
Death rtificate Filed District Number : Register Number
ow or Village
Date Cemetery or Crem5Sg
❑Burial
uJ l
6£remation i, Addre
. ... ........................................................................................................:......::::::::::::.
Zi! Date Place Removed
❑ Removal and/or Held
and/or Hold :::::::::: ::::::::::::....::::....:::::::::::::::::::::::::::::.,.:::.::::::::.:;>::::::::::::::::::::::::::::::::::::::::._:::::::::::::::::.::::::::::::::::::::::::::::::: ......::::
Address
O>:...............:.::::::::....>.:::::::::::::::::::::.......... ::::::::::::::.::::::::::::::::::::::::::::::::::::::::.::::::::::::.:::::::::.::::::::::::::::::::::::::::::::::::::::::::::......:::::::::::.::::.::......::::.:::::::::::::.....,......:::::::.
12 Date Point of
N; ❑Transportation by Shipment
Common Carrier ......................................................................................................................................................:.............................................
Destination
........................................::::::Date,:::,:..................................................... r�::::: .......................................................................................................
❑ Disinterment Cemetery Add ess
1e.:::::..................................................... A8:::,:........................................................................................................
❑ Reinterment
Da CemeteryAddress
Permit Issued to : Registration Number
>`> Name of Funeral Firm , •
.0 �sV /ZJ
s c D
c�
Address
r2j ti
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
PP
€.T
Address
.......................................................................... ......... ......
Permission Is erey granted to dispose of the human remains described above as Indicated.
Date Issued 0 O Registrar of Vital Statistics
/ (s 'lure) u,
District Number /, Place 2,1/A:1411
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition f3/"90 Place of Disposition
I (address)
>w
(section) (lot number) (grave number)
o g 0.. Name of Sexton or Person n Char a of Premises
Z, (please print} -� �/
11J.
Signature Title .E"�If�/o�/ ���
i
DOH-1555 (9/86)p 1 of 2(formerly VS-61)