Kemp, Rebecca 2�o1vtN OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director1) C)1� IV E
Name h-e—,VsO Case # /5-
Date of Cremation l f
Time Cremation Started /z
Time Cremation Completed
Type of Container k
Remarks :
A l /q
12 /11
No.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent
Decedent's address Vergennes, Vermont
Date of death Apr. 13, 1996 Place of death Burlington, Vermont
Cause of death certified by Sieplien Adams, M.D.
Permission to cremate the body of this decedent at Pine View Crematorium
Queensbury, New York
(Name and address of Cremator%)
has been requested by Douglas V. King, Durfee Funeral Home
(Funeral Director)
Vermont F. D.
tl6 119 No. Main St. , Fair Haven, Vermont 0574
License No.
(Address of Funeral Director)
Being sufficiently informed as to the causes and circumstanees,ef the death of the above
described decedent, permission is hereby granted ii cremate the ody as requested.
Date , C (Sign , , Examiner
Address ,l_
18 VSA SEC.5201 (b)
n
TOWN OF OUEENSBURY
PINE VIEW CEMETERY
A
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 :
Rebecca Lynn Sears Kemp
(Sex)
(Name)
Trailer Park Ver Vermont 05491
(Street ) (City) (State) (Zip Code)
who died on
13th day of April 19 _
at Burlington, Vermont
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Patricia Ann Sears, 34 Pinetree Lane, West Lebanon
N.H . 03784
Harold A Sears Rte. 4A Rnx 266, Hydevi i P vT
5756
(Name) (Address)
Relationship to the deceased Parents
Name of Funeral Home
Durfee Funeral Home
IMPORTANT: knowledge, the deceased has or
I represent that to the best of my as no (Circle One)
pacemaker in his or her body.
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
defend
been removed or may be destroyed, and agree to protect,
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
or demands are or are not wholly
d ' rected, whether such claims
r undless, false or fraudulent.
U.
�/ A 119 No. Main St . , Fa ' 05743
(Witness) (Address)
34 Pinetree Lane, W. LEbanon, N.H.Rte. 4A, Bo 26 , Hydeville, Vt 05750
(Signature of Relative or Legal Rep. and Address)
Signed on this date : April 15 , 1996
i
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify : L, ,'LL P jQ 2
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
I. The crematorium will be open for cremations 5 days a week
7:00 A. M. - 3:30 P. M. Monday-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 said remains and/or disposition of said
remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent. This authorization
in addition to a regular burial remains. permit must accompany the
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 $20. 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $1B5. 00
Children (age 13 months to 12 years) t11.0. 00 Infants
to 12 months) $ 70. 00 ( stillborn