Duffany, Walter jouln v ueen:s ar .
f iNE VIEW CENICTERY and CREMATORIUM
QLIAI(F.R ROAD, QUEENSQURY, NEW YORK 12801
(518) 798 4 72G
(518) 793-9777
FUneral Dirictor
t1�mP. ► Case No. " cz /
Dale of Cremation
Tinr CrernaLion Started
Time Cremation Completed
!�1 of Container �9404AM /'.5 l`��
Pcina k s _(1�l /t
r. yf/J" df,41
_ No <f;oc!14 .1-7e4)AI
vvv ice• �,._ .ice•vi, , LI\LV1J I LI\ r v 7C.ICr'IL JV�..OCJG JOG1 JClf f-',1/1
Vermont Cremation Ser-vice
Box 957
213 West Main Street
Bennington, Vermont 05201
CREMATION AUTHORIZATION
STATE Cremation Number
COUNTY OF: Cremation Date E
(for cremation use only}
The undersigned authorizes Vermont Cremation Service ("Crematory"), in aoaordanee with and subject to its Rules and
Regulations, to cremate the remains of W41-7L L)ti L -]g�C . I
who diod at IIt�, c^t_",: rt-1l�- t'h�- c�,. on the J-2 day of_ ,18 9X at tho ago
of , years and agrees to 1�responsible for and pay all charges incurrs with respOCI la this authorization,
The Funeral Director in Charge Is h _ L, (Funeral Director).I further state the death
U was '� was not due t0 infectious or Contagious disease_
i 1 understand that if I do not notify the Crematory about a death by infectious di:iease, that I will be liable lov, hr*iy darrratglrs
to the Crematory or Injury to Crematory personnel.
It is requested that the following disposition be made of the remains:
Yam'PIOCe the cremated rernains in&c:�e y �a i►+-f Cemetery- tees furntsned upon request.
Delivery to e5i The undersigned hereby authorizes Crematory to deliver Ihs
egisrn
cremated remains Via Rtd Mall and agrees to assuma all liability for any damages that may arise from any cause
growing out of said deliverer and to indemnify and hold harmless the Crematory and the Funeral Director from any and all
claims related to saidshipmerd-
p r,To be called for by f -.4 z�r fi
f hereby certify that I am related to the deceased a9 SQ&-. the deceased died of natural causes, and I have
the right to authorize this cremation and the disposilion 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! t understand that cremated remains
are bone fragments, which will be reduced in size and placed in an um. Urns provided by Crematory are sufficient in size
for all cremated remains, In the event the Capacity of the um I eeleced elsewhere is lead than the amount of the cremated
remains,Crematory is hereby authorized to return said excess cremated remains in a temporary container, 1 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-
1 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 Crematory or injury oil
amatory pensonnel.
Signed:R1W
Address: C�
city:
WITNESS: State/Province:
n requ a Neu _ 7 a
Zip:CSyJ( Telephone: 'WL1p4
Date_
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