Eastman, Lettie T074N OF QUEEVBUWY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director kh &l Zlflv
Name / / /� //S�/��/Z Case #
Date of Crematicn — �
Time Cremation Started _t l �
Time Cremation Completedzd-ti66 141m ,
Type of Container '�'7 49y_&1#/1
Remarks :
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?(RON OF OUEeNSBURY
d PIt- V LSW CEMETERY
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CREMATORIUM
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Cemetery 743 -4476
AUTHORIZATtON TO CREMATE
The undersigmvd requests and authOelzvs pine viOw Cr,1)matgr.ivmq . In
accordance with and subjgct to its Rules ,and Regulations tQ
crematV tH 9 remains oft
Mrs . t.et,lia. I'f!mnir
99 Allen Ave. Rutland Vermont Q57QI
(StrMe.t.) ieity) (state) ( lip Code)
who died an , . 2 clay of jdaua"-' 19 ___98
99 Alld n p,ve
at Edon Park Wrsin Homo Rutlan , Verm<)rit 05701 .
(Place.) (Address)
NAMM A"A aNdrra• A# mear.st livinn ralative or name of C31fY" o6
authorizing ereMationt
AlnO14 UexLer
(N�MMe (Addrws s) rt
Relationship- to the deceased Nephew
NAVV of 04AwWV4i1 WOO* . Roberts.,Aubin Funex.a]
I�R1ANi1 . .
I reprrsent th4t to the best of my knowle490, the do.fevi►sed has or
0# no papemaker,)i n his or her body. (Circle One)
I cerrt i-ty that I haven the full power, and author+i tat l on to arrange
fpr the cy-ow4tion of the remisins and to direct the disposition of
the cramat'etl remains., zmai any personal possessions have, eltriwr
bloom reweved or may be destroyed., and ,agree to pr+atecti . deff"d
•nd s,avv. hare l tss P i"o V i ew CrMmst 00-1 tAn #wd* any ,sad - 41 1 P*i w i+K
Ono v.aand» roe loss► n, duaaors which say br ssdr ,roainot thorn bV
reason of or connected with the cremation of said rwgain• as
directed, whether such claims or demands are or awe not wholly
groundlesly false or fesudulent.
tWiiitn (Address)
tn
� . isign'"Aur. of Relative v qml Rep. and Address)
Stoked oh this deter
No.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent Mrs. Lettie Eastman
Decedent's address Eden Park Nursing Home, 99 Allen Avenue,Rutland, Vt.
Date of death January 22, 199$lacc of death Eden Park NUrsina Home
Cause of death certified by Dr. Michael Bell.
Permission to cremate the body of this decedent at Pine View Crematorium
Quaker Road, Queensbury, New York
(Name and uddresiM of Cremalory)
leas been requested by James Auxin of: Roberts-Auxin Funeral Home
(Funeral Director)
Vermont F..D. 1030 17 Allen Avenue, Poultney, Vermont
License No.
(Addn•iw of Funeral Uin•rlor)
Being sufficiently informed as to the causes and circumstances of the death of the above
described decedent, permission is hereby granted to cremate the body as requested.
Date January 23,1998 (Signed) , Examiner
Dr. Michael Scovner
Address Green Mt. Collecre,POultney,Vt.
18 VSA SEC 5201 (L)