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Hughes, Vincent own v ueenj ltr y. rir1E VIEW CEMCTERY avid CREMATORIUM QLJAKFR ROAD, QUEENSCURY, NEW YORK 12801 (518) 798 4 726 (518) 793-9777 Funeral Dirictor �/�,L)//te/� �5• Case No. '302tl, Dale of Cremation Tinwr Cremation Started 0 Ti me Cremat ion Completed L '1}•1vl oC Container 197�L'i( O �y �' d5,6�T /f // - . P/ TOWN OF QUEENSHURY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 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: Vincent Andrew Hughes Male (Name) (Sex) 510 Red Wing Street Round Lake Beach, I1. 60073 (Street ) (City) (State) (Zip Code) who died on 6th day of Nov. 1992 at Chicago, I1. 2706 Thomas Street (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : Virginia Hughes 147 Westerfield Place Grayslake, IL.. 60030 (Name) (Address) Relationship to the deceased Sister Name of Funeral Home Flynn Bros. Inc. Schuylerville, NY 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, hether such cla ms or demands are or are not wholly undle fa ent. 13 Gates Ave. Schuylerville, NY 12871 i ne s) (Address) 147 Westerfield Place Grayslake, IL. 60030 (S' gnature of Relative or Legal Rep. and Address) Signed on this date : Nov. 13, 1992 v • . DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify : Will Pick up If pulverization of cremate remains is requested, check here X POLICIES, RULES AND REGULATIONS 1. The crematorium will be open for cremations 5 days a week 7:00 A. M. - 3: 30 P. M. Mondav-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 of 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 be made against them by reason of or connected with the cremation of s:- d remains and/or disposition of said remains as directed, whet er 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. 6. 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 $15. 00 charge for this service. Cremation, Administration Costs and Recording Fee : Adult $155. 00 Children (age 13 months to 12 years) $90. 00 Infants (stillborn to 12 months) $50. 00 — — — — — — — — — — — — — — — — — — — — — -- — — — — — CERTIFICATION OF NEXT OF KEN FOR CRF.MAMN I. Virginia Hughes:. )WME$x' CERTIFY THAT I AM 7HE CLOSEST LIVING REIAATWE OR N = OF )UN OF Vincent Andrew Hughes , 1?ECEASED. I FURTHER CERTIFY THAT NO OTHER REI..ATIVfi OR PARTY IN INITP.F.ST HAS OWEMD TO THIS CREMAT1014. SIONAIVRE 147 Weste field Pla a ADDRE.�S Gr,j CITY- 708,) 548-1453 �'8L$PHONE RvAnomw r•• r- — NOTARY PUBLIC SECTION S7 ASP WORN WORE us TN11 U1iTm NgrA.RY AtAL RELVA) AV C 34 L TI ,ulY Pui1t.1C MY comma uox Sx�s -OFFICIEwira . Og F AstM► hi►lieis Ily comohsi /u .IS�k1f:L41fR\11'< r,'Q\ A+',r. Y.U.1'.:f,� :.Y.talliil�GlU:1 \ ' ,� •fi• °,ail'ail'�5 �c _•'Iti'l:R�'�1�1':37Y'S1TA2''fxln 7234 STATE OF ILLINOIS Permit No. c. COUNTY OF COOK Date Issued I k 1A MEDICAIL.EXANNER'S1 CORONERS=PERMIT TO CREMATE,&YEAD.BODY Full Name of Decedent Decedent's Address Date of Death \Vt Place of Dea Cause of � Cause of Death Certified by 0 Permission to cremate the body of this decedent at i1G-9 Q V ul (Name and address.ol Crematory) Ir has been reauested hv -Ir me and address of funeral home) ftheral Director's Iflinois License No. x (Signature of funeral director) Being sufficiently-ii4ormed as to ft'cause'd and-circumstances of the death of the above described decedent, permission is,hereby granted to cremate the body as requested.- Date jSigh6d Medicall'Examiner/Coroner A;Sw< (MEDICAL EXAMINER/RORONER-WHITE) (CREMATORIUM-CANARY):(REGISTRAR-PINK) (FUNERAL DIRECTOR-GOLD) VR-204.1(6189r) THIS PERMIT IS REQUIRED FOR THE CREMATION OF,A DEAD HUMAN BODY 1. A dead human body. cannot be cremated without this permit. (See section 10.3, Chapter 31, an act to revise the law in relation to coroners, com nonly:known as The Coroner's Act.) _ 2. The funeral director.can obtain this permit ONLY from the medical examiner/ coroner who made the investigation. 3. The local registrar shall NOT sign the report (VR205) or issue a Permit for Disposi- tion of Dead Human Body (VR204) authorizing cremation of a dead body, unless the funeral director presents a completed Medical Examiner's/Coroner's Permit to Cremate a Dead Human Body plus a complete and satisfactory certificate of death. 4. The report (VR205) or Permit for Disposition of Dead Human Body (VR204) must be accompanied by the Medical Examiner's/Coroner's Permit to Cremate a Dead Human Body when presented, with the body, to the crematory. 5. The Medical Examiner's/Coroner's Permit to Cremate a Dead Human Body should be retained by the crematory and local registrar, subject to examination by the medical examiner/coroz ion of Vital Records. e s �.�. e fi2 STATE OF ILLINOIS m-Per it No. 34- COUNTY OF COM Date Issued MEDICAL EXAMINER'S /,CORONER'S PERMIT TO CREMATE A.TEACI BODY Full Name of Decedent i Decedent's Ad ress k 74�1 Date of Death AA PI of D 1, � Cause of Death 0 Cause of Death Certified b`y Permission to cremate the'body of this decedentat \o L-�N < (Name and address of Crematory) cr w - has been requ' e -� LL requested b t� , x ,and�I X N\ \-�-� L, z `77 a address of funeral home) :4 12,19-7741-2— Funeral Director's Illinois License No. (Signature of Illneral director) Being sufficiently inform&I to the causes and-circumstances of the death of the above described decedent, permission is hereby granted to ore ff at the body as requested. Date (Signed) Medical 6 ner/Coroner (MEDICAL EXAMINER ORONER-WHITE) (CREM TORI.&A-CANARD (REGISTRAR-PINK) (FUNERAL DIRECTOR-GOLD) VR-204.1(1111/w) THIS PERMIT IS REQUIRED:FOR THE CREMATION OF-A DEAD HUMAN BODY 1. A dead human body cannot be cremated without this permit. (See section 10.3, Chapter 31, an act to revise the law in relation to coroners, commonly known as The Coroner's Act.) 2. The funeral director can obtain this permit ONLY from.the medical examiner/ coroner who made the investigation. 3. The local registrar shall NOT sign the report (VR205) or issue a Permit for Disposi- tion of Dead Human Body (VR204) authorizing cremation of a dead body, unless the funeral director presents a completed Medical Examiner's/Coroner's Permit to Cremate a Dead Human Body plus a complete and satisfactory certificate of death. 4. The report (VR205) or Permit for Disposition of Dead Human Body (VR204) must be accompanied by the Medical Examiner's/Coroner's Permit to Cremate a Dead Human Body when presented, with the body, to the crematory. 5. The Medical Examiner's/Coroner's Permit to Cremate-a Dead Human Body shoujo.: be retained by the crematory and local registrar, subject to examination by:the medical examiner/cord 'v a �: ion of Vital Records. a STATE OF ILLINOIS PERMIT Ncfy20331 ORIGINAL PERMIT FOR DISPOSITION OF DEAD HUMAN BODY ��4) �� C SED- NAME I d/)V) Vim MIDDLE /�il/�+ �� T SE� (DATE OFj D��®ATH (MONTH YEAR) A E—L OF DEA H COUNTY (CITY, TOWN, TWP. OR ROAD DISTRICT NUMBER// U.S.WAR VETERAN Z BIRTHDAY JPLAtE COOK CHICAGO (YES/N f— (YRS.) Q DISPOSITION AUTHORIZED z ElHOLD BODY BEYOND 72 HOURS aky� hoN C•� w ❑ INTERMENT, ON (DATE) _ OF DISPOSITION (NAME AND LOCATION OF CEMETERY,CREMATORY OR LABORATORY) p CREMATION, ON (DATE) `tee ez't,I �❑ TRANSIT [] DISINTERMENT F DISINTERMENT (NAME AND LOCATION) y ❑ SCIENTIFIC STUDY ❑ REINTERMENT iAIS16Vo/c/c T `IRE N F ILLINOIS LAW IINNG B ENaMyET, THIS ERM TO DISPOSE OF A DEAD HUMAN BODY ISSUED TO: / �y m ✓�' / `f �/" /!J v" FUNERAL DIRECTOR;. ILL. LICENSE NO. 7 400�y�(lJs ZQ ADDRESS: CHICAGO, ILLINOIS O U (� � 4 U DATE: NOV 0 9 �(199E (SIGNED) Wi � LOCAL REGISTRAR Q C CAGO DEPARTMENT OF HEALTH 0 REGISTRATION ADDRESS: ichard J.Daley Center,Room.99 _ •• -•BY' "' DISTRICT NO. ncourse Level,Chicago,IL 60602 SEXTON'S ENDORSEMENT: ~ THE BODY ACCOMPANYING T IS PERMIT WAS RECEIVED AND WAS; INTERRED/CREMATED ON O ,19 ,IN v CEMETERY OR CREMATORY—NAME a LOCATED AT VC�LJiF_ N C7I//C i /r C (SIGNED) �E SEXTON GRAVE OR VAULT: BLOCK_ ' LOT GRAVE SEE OTHER SIDE VR 204(P.O.X033AA 87.5 M 9/91) ILLINOIS DEPARTMENT OF PUBLIC HEALTH-SPRINGFIELD