Kennedy, John 5ouln v ueeni "'r .
rlrlE VIEW CENICTERY and CREMATORIUM
QIIAKFR ROAD, QUEENCQURY, NEW YORK 12801
(518) 798.4 726
(518) 793-9777
Funeral Dirictor �',�,, �
Case No. 02 J O
UnLe of Cremation
'1'inM Cremation Started
Time Cremation Completed
1}1 of Container •A/' IlyDUp �, ,zL �� �.�� 4 /h%Eel /�
Ald
1� �2/1
AL
14 44
i/ 12--P 4)A1
Vermont Cremation Service
Box 957 r�
. 213 West Main Street
Bennington, Vermont 05201
CREMATION AUTHORIZATION
STATE _/(,() 1�� � Cremation Number
COUNTY OF Q /�.SS�=T�/��� Cremation Date
(for cremation use only)
The undersigned authorizes Vermont Cremation Service ("Crematory"), in accordance with and subject to its Rules and
Regulations, to cremate the remains of 3-014N �D S Er-( t�'4NN,!t-V Y
who died at cm2y ,eb `/ on the 10 day of t—JU 19 YZ—at the age
of Z_years and agrees to bee responsible for and pay all charges incurred with respect to this authorization.
The Funeral Director in Charge is/77fl -5 & �,i �// (Funeral Director). I further state the death
❑ was O'was not due to infectious or contagious disease.
I understand that if I do not notify the Crematory about a death by infectious disease, that I will be liable for any damages
to the Crematory or injury to Crematory personnel.
It is requested that the following disposition be made of the remains:
❑Place the cremated remains in Cemetery - fees furnished upon request.
❑Delivery to The undersigned hereby authorizes Crematory to deliver the
cremated remains Via Registered Mail and agrees to assume all liability for any damages that may arise from any cause
growing out of said delivery and to indemnify and hold harmless the Crematory and the Funeral Director from any and all
claims related to said shipment.
To be called for by %1 /y!/qS /21 md r/C �Uitlr�iK /�DLl/
1 hereby certify that I am related to the deceased asf _ the deceased died of natural causes, and I have
the right to authorize this cremation and the disposition of the cremated remains. I understand that due to the nature of the
cremation process any valuable material, including dental gold, will either be destroyed or not be recoverable. Any personal
possessions accordingly have either been removed or may be destroyed. "If the container or any portion thereof is not suitable
for cremation, Crematory may require the remains be removed to a suitable container.' I understand that cremated remains
are bone fragments, which will be reduced in size and placed in an urn. Urns provided by Crematory are sufficient in size
for all cremated remains. In the event the capacity of the urn I selected elsewhere is less than the amount of the cremated
remains, Crematory is hereby authorized to return said excess cremated remains in a temporary container, I further agree that
I will indemnify and hold harmless the Crematory and Funeral Director, their officers and employees from any liability, costs,
expenses, or claims resulting from this authorization.
I further state that the deceased has not had a heart pacemaker implanted, radiation producing implant device nor any other
life sustaining device that could be explosive. If such a device exists, I have instructed the funeral director or others to remove
it before cremation. I also agree that in the event of my failure to notify the funeral director or any others responsible for the
removal of such a device, I will be liable for any damages to the Cr atory or injury to Crematory personnel.
Signed: ` C�
Address _�� 7 �C�yGS� 'JJ^
City: y 1
WITNES State/Province: /" Lc_J
(can re ui rNotarleal) /
Zip: /Z��(� Telephone: 7� � Gli,
Date: / L--