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Munger, Madlyn 70q4N OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Rob Q.r Ub Name A- / -Y Jk A19 e (- Case Date of Crematicn C( - O n^ Time Cremation Started Time Cremation Completed Type of Container C A ra Q nAr I Remarks : s r TOWN OF QUEENSBURY 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: Mrs . Madlyn Rowe Munger Female (Name) (Sex) 6 Carnarvon Street Fair Haven, Vermont 05743 (Street ) (City) (State) (Zip Code) who died on .C� day of ©beg u . 19 at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: Mr. Everett H. Munger 6 Carnarvon Street,Fair Haven, Vt . (Name) (Address) Relationship to the deceased Husband Name of Funeral Home Roberts-Aubin Funeral Home IMPORTANT: I re that to the best of my knowledge, the deceased has or has �nresent o acemaker in his or her body. (Circle One) 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 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 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. (Witness) ' (Address) Signature of lative or Legal Rep. and Address) Signed on this date: DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify: T If pulverization of cremate remains is requested, check herej� POLICIES, RULES AND REGULATIONS 1. 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 permit must accompany the remains. 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 $175. 00 Children (age 13 months to 12 years) $ 100. 00 Infants ( stillborn to 12 months) $60. 00 No. STATE OF VERMONT EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY Full name of decedent Madlyn Rowe Munger Decedent's address 10 Carnarvon Street, Fair Haven, VT 05743 Date of death Oct. 8, 1998 Place of death Mountain View Genesis Eldercare Cause of death certified by Dr. Peter Dierksen Permission to cremate the body of this decedent at Pine View Crematory Quaker Road, Queensbury, New York 12804 (Nume and uddr"pl of Cremulory•) has been requested by _James C. Aubin of Roberts-Aubin Funeral Home (Funeral Direelor) Vermont F. D. 1 030 266 Allen Ave. , Poultney, VT 05764 License No. (Addn•�M of tlnu•rul Din•elor) Being sufficiently informed us to the causes and circumstances of the death of the above described decedent, permission is hereby granted to cremate the body as requested. Date Ont-nhar Rr1 AAR (Signed) , Examiner Address o-Glty� 'S.T �� t/ `, 18 VSA SEC 5201 (L) l � 7