McDonald, Catherine T074N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name (°A'rt' AZ ,P. R id-LE MC A04 .,Igkase # 9,0
Date of Cremation
Time Cremation Started It I
Time Cremation Completed l0 t Q 10 A rYl /
Type of Container CArr± fins tel 157 CAs -e OZ�7-4 e D Ax
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Remarks :
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TOWN OF (2uEENSHIlRY
DINE VIEW CEMETERY
CREMATORIUM
New YorK :2804
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AUTHORIZATION TO CREMATE
The 4^1de,s P'.- "ec :lests and 5ut"'Orjzes Dine View In
dCr'Or�3^� e with to its Rules and Regulations to
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IMPORTANT
rep-ose^t t (D tt-e 'pest of my knowledge, the deceased has or
as ne eacemaker .n has or her body_ tCircle One)
I cer^ ; fv that 1 have the f�..l l power and authorization to arrange
For the c-emation of the -Pmalrs and to direct the dispr7sitlon of
tt--Q C.-emated remains, that any personal possessions have either
bee- -emoved ' - may be destroyed, and agree to protect, defend
and save �N rnless mine View Crematurium Fro+n any and all claims
and s!ema�d ror loss er damanes which may be made against them by
reason of or connected wit,-, the cremation of said remains as
direc` Pe!, whet}-er such claims or demands are or are not wholly
9-o,.;nd audu 1 ent.
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NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First a Middle Last Sex
...................� ................ ... ... ... ... ..... ._.....
Date of Death Age If Veteran of U S Armed Forces
g War or Dates
� ... ..
Place of Death Hospital, Institution or
� City Town or Village Street Address
.:
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Manner of Death undetermined Pending
Natural Cause Accident Homicide Sui 11e
Circumstances Investigation
..................
Medical Certifier Name
Q _ . .................... ................. .
Address
.. ....... ..... .. _....
_._
Death Certificate Filed District N ber Register Number
:. ..:
City,Town or Village
Date , Cemetery r ma ory C r----—
..... .. .:::.:...:
El Burial 4 ......../�...����...:::... :.. : :::: ....:...:�1:::
Cremation
Address
...........:.
Z Date PI c Remov d
0 ElRemoval : a d/or Hel
H' and/or Hold ::..............:..::.:........ .:.:..:.: ..... ... ....: ....:::::- ...... .::: :::: ........ ... .- :..... . - :::::
Address
N>'
0. _..:::.....................;:..:............................. .. .......... :.. __ _.......
OL Date P: oint of
cni; []Transportation by': Shipment
p' Common Carrier
..........:................. . . ......... ...... ......... . :....... ... .........................
Destination
.......... .. ..... ........
❑ Disinterment Date Cemetery Address
..... .. ..... ::.. .... ......... ........... ............. _. ............
❑ Reinterment : Date Cemetery Address
Permit Issued to Registration Number
egistrati um
Name of Funeral Firm
Address [�
....... ..... .... (.. ......... ...... ..........
�- Name of Funeral Firm Makinpro or to VNh
Remains are Shipped, If Other than Above
.. ................................................:.....:.:..............:....:...::.........:::.... ..:........................................ .....
Address
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Permission is hereby granted to dispose of the human remaj7fs described above as indicated.
Date Issued `' Registrar of Vital Statistics
(sign_ ure)
District Number Place ✓
1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Z' Date of Disposition Place of Disposition y e, / r—r e 11 a-7—a i-
W` (address)
W''.
(section) (lot number) (grave number)
0'
p Name of Sexton or Person in Charge of Premis s i('/7 o et AoPeZ
Z (please print)
W' Signature Title [',P�/ri cLTo rY �—
DOH-1555 (10/89) p. 1 of 2 VS-61