McCann, Marjorie E. jott/pt U uee2:S ur .
rIPJE VIEW CENICTERY avid CREMATORIUM
QUAKER ROAD, QUEEE,798UI?Y NEW YORK 12801
(518) 79;3-9777
Funeral Dirictor f)u
Case No.
Dale of Cremation —1 —
,rinM Cremation Started _
,rime Cremation completed �--
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No. 2-
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
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Full name of decedent arjorie Evelyn McCann
Decedent's address
R.D. 1 • �Box 222 Orwell Vt- 05760
Date of denth Aug. 14, 1991 Place of death Rutland Regional Medical Center
Cause of death certified by Dr. James Wallace, Jr.
Permission to cremate the body of this decedent at Pine View Crematorium
W-ueensbury, N.Y.
(Nucor and nddrrsis,of Cremulory)
has been requested by _ Douglas V. King, Durfee Funeral Home
(Funerul Direelor)
Vermont F. D.
License No. 6 Fair Haven, Vt.
(Addreso of Funeral Direelor)
Being sufficiently informed as to the causes and circumstances of tl death of the above
described decedent, permission is hereby granted rc to t od s requested.
Date _ (Signed) ) finer
Address
18 VSA SEC 5201 (L)
DI1 P08111ON OF CREMATED REMAINS
1 hereby dire sit Pine View Crematorium to dispose of the cremated remains as follows:
Mail to C ,h
Other arrangement - please specAl'fy:
if pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday.
No holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone
for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker
Road, Town of Queensbury.
3. An authorization for cremation properly signed by the nearest next to kin or other authorized
person stating that they do have the power and authority 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 of damages which may
he made against them by reason'of, or connected with the cremation of said remains and/or
disposition of said remains as directed, whether such claims or demands are, or are not wholly
groundless, false or fraudulent. This authorization in addition to a regular burial permit must
accompany the remains.
4. All remains must be encased in a casket or suitable Alternate container. Caskets and
containers must be of combustible material. No styrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
F. Unless other arrangements are made, the cremated remains will be mailed via Registered
U.S. Mail within three days of cremation to the funeral home handling the service. There
will be a $10.00 charge for this service.
Cremation, Administration Costs and Recording Fee:
Adult 055.00
Children (age 13 months to 12 years) $90.00
Infants (stillborn to 12 months) $50.00
� 24�
TOWN OF QUEENSHURY
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTIiORIZATION 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:
Marjorie Evelyn McCann female
Name Sex
R.D. 1, Box 222 Orwell Vermont 05760
Street City State Zip Code
who died on 14 day of August 91
19
at Rutland Regional Medical Center, Rutland, Vt.
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Bernard McCann . R.D. 19 Box 222, Orwell, Vt. 05760
Name Address
Relationship to the deceased Husband
Name of the funeral home Burfee Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o
or has no pacemaker in his
Kee 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 d' ed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
Witn ss Z
Signature of Relative or Legal Rep.
119 No. Main St. R.D. 1 , Box 222
Fair Haven, Vt. 05743 Orwell, Vt. 05760
Address
Address
Signed on this (late Aug. 14, 1991