Bascom, Alice OF QUEEVBU-' �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director , met-
Name L rn Case #
Date of Cremation
1
Time Cremation Started r(11 O M
Time Cremation Completed
Type of Container C A196 c -e P4 n 'e-
Remarks :
M/2//1/ Z ld eh/Y -lf fI/tr' l b �0 O R1 i
Taw OR aKiEENSBURY
PINE VIEW CEMETERY
d
C REMATU R I UM
Quaker Road, oueensbury, New York 12804
Phone (51A) 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
r_rvoAte the remains oft
Alice C B_ascom Fp.0 1
4 Grove St. Fort Edward, New York 12828
(street ) (City ) (State) (Zip Code)
who died an Aug. 8, 1993 day of 19
at Glens Falls Hospital
(place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Debbie Eberhart 70 Searles Rd. Nashua, NH 03062
(Name) (Address)
Relationship to the deetaled daughter
MI
Name of Funeral Home M. B. Kilmer Funeral Home
IMMRTANTv
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 alltharization 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 Cremet'orium 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
groundless, false or fraudulent.
/V• I-�
(Witness) (Addre )
(Signature of Relative or egal Rep. and Address)
Signed on this dates 3
�i� ww..�r pair—���i�
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle LV 1 Se /
Date of Death Age ry If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution r
City, Town r Village ( /'f(O//� Street Address w Q�{Ci�'/ ►/Pr /'�/
Manner of Death Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑ 4w-
ending
Circumstances Investigation
Medical Certifier Name Title
.1 lei�crn mb
AddressSti- 1
zr
anvd�, NY
Death Certificate Filed District Number Register Number
City, Town or illagerQ
DateT Cem `ry or C a�matory
El Burial U-QC l gq� e view - rPm tr
Address
Cremation �'f,�j /'UYNY
Date Place Removed
Z❑Removal and/or Held
and/or Address
Hold
Q Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home p
Address
Gar 'a�?vl'IL�
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ins described ab Tve s indicated.
Date Issued Registrar of Vital Statistics
r (s at re)
4'
District Number
Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition �a` Place of Disposition
(address)
UJI
W
M (section) (lot numb er .�J ( rave number)
GName of Sexton Person i Charge of Pre ises � /Qi /� /7' /��i7 41
(please print)
U. J Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61