Coombe, Dorothy T0cW OF QUEEVBU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name '_ C�r AbQ-Case # L"l
Date of Cremation
Time Cremation Started U . �J `
Time Cremation Completed 0 0 fy) 10-
Type of Container �6�c1Z� x)J\ CdSP`c�-1����3
Remarks :
Al 9i/N ►C30l?W�i�
�� �� �G • bG /p r
11 Il
rc vY
GroUnosersf, fall! 5
� t
yL _``• .:.:'Z''it`'.'' �..- rt,-. irt'l _ ., +�-` __^ ."�� C•,.t; st__t ��#r�,r,"' _ V IZCN LL'
` Si is e ReI-act xv'? : �V �;�I Rea, and+ f�d t
No. ,.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
ti
Full name of decedent Dorothy Rosalee Coombe
Decedent's address 28 Prospect St. , Fair Haven, Vermont 05743
Date of death Jan. 25, 1997 Place of death Sager Nursing Home, Fair Haven, VT
Cause of death certified by Stelphen Rosmus, M.D.
Permission to cremate the body of this decedent at Pine View Crematorium
Queensbury, New York
(Nume and uddmiias of Crrmulory)
has been requested by Douglas V. King, Durfee Funeral Home
(Funeral Director)
erm
Vermont F. D.
sc F. #16 119 No. Main St. , Fair Haven, VT 05743
Licen (Addrepir of F usieral Din clor)
Being sufficiently informed us to the causes and circumstances of the death of the above
described decedent, permission is hereby granted to cremate the ody as requested.
Date Z7 g/7 (Signed) L ��//�� E/x�aminer
Ad css
18 VSA SEC 5201 (b)