Hogarth, Leona �O` 4)N OF QUEEVBWU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_�� � ,�/—D��
Date of Cremation b5 `" T- / -3
Time Cremation Started
Time Cremation Compl et ed� 3c2 A/ Al t
Type of Container 17 di►f2den S1�G'/7jic�
Remarks :
4176 //,-ram ,/9 1�?.nZ
41 iJ
dziyl
f 141
TOWN OF QUEENSBURY -�
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 reauests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
�'�6�' C9 to r S]- ��-C-
(Name ) (Sex )
(St:reet ) (City) (St t ) (Zip Code) (� 2
who died on day of `��r��ZC4 19 1 J
(Place) (Add ess ) 13
Name and address of nearest living relative or name of person
authorizing cremation :
(Na e) (Address
Relationship to the deceasedEga &K�) P�4 QC)WuL CIF A-T-xOCWF-�
Name of Funeral Home
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
groun ss, falsg or fraudulent.
ity� ss> (Address ) &x�� ' , f�
(Signatures'' '` of Relative or Legal Rep. and Address)
Signed on this date : _ — 111
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Se
.. V..... _. �: . _ ,oC .. : .......
Date of Death Age If Veteran of U.S.
Armed Forces
— — War or Dates
F— ............
Place of Death Hospital Institution or
City Town or Village Street Address d
0 Manner of Deathatural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
U ....... .................................. ....................................................... .... ...... ... ....::... ... ...::......... _ -..... . ..::: ......
Medical Certifier Name \ , Title
Address
: .......�. . .�u.tt.G-.......:1��.t�.." 1. C{ � -CZ : :: �. .......Death Certificate Filed District Number Register Number
City,Town or Village ��.rti5
Date Cemetery or Cremator
ElBurial
t i ( y
remation
Address
............................. ........... ................... ...... ............ ...... ...... .......... ......
Z Date Place Removed
OI Q Removal and/or Held
1- and/or Hold .. . .......:... -..-.....,. -........ --::::.... .... .. ..... .::::.
Address
F
0......... ......... ..... . ..... . ........... _ _.............. ........
CL Date Point of
N Transportation by: Shipment
C1 Common Carrier ......... . .... ... : ..:..:........-._:... ...... ......
Destination
....................................... ..::.........:.... ......... ......... ...............
Disinterment Date Cemete Address
.: ................ ...... .....................: .::... . ..... ... ......
....
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm. "-........ _.....: ..
Address
........... n c cat . : �. : \ : _G�cac 'r� -�' s
Name of Funeral Firm Making Disposition or tAhom
Remains are Shipped, If Other than Above
. .. ,. ...... ..::.................:: ... .. .:..
� ::::Address .::::. _,,::.:... _::.:. ..............
ut
iL>
Permission is hereby granted to dispose of the human emains ascribed a ve as i icated.
Date Issued - 1 Registrar of Vital Statistics
ure)
District Number j 60/ Place C t
I certify that the remains of the decedent identified above were disposed of in accordanc ' h this permit on:
WDate of Disposition Place of Disposition
2' (address)
w
M'', (section) (lot number) (grave number)
p> Name of Sexton or Person in Charge of Pre ises
Z (please print)
W Signature Title� �d ' '
DOH-1555 (10/89) p. 1 of 2 VS-61