Langlois, Clifford y s
70 g+N OF QUEENs5BU-1KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorL 'aEx AVE/_0 ` )Y:�/r/ o�:-
Name �-` �� L! �/7/U-i�C� l Case # f7� �
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Date of Crematicnz&
Time Cremation Started /'0/ 'Yt
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Time Cremation Completed
Type of ContainerCdRD&dZD
Remarks :
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AUTHORITY TO CREMATE
(This Authority,signed by the proper relative or legal custodian of deceased,together with Burial Permit,must be filed at
the office of Adirondack-Burlington Cremation Services before cremation may take place.)
I hereby request and authorize Adirondack-Burlington Cremation Services to cremate the remains of:
Male 82
Clifford Joseph I,anglois (sex) (Age)
(Name)
P.O. Box 175, Alburg, Vermont 05440
(Street —city—State— Zip Code)
who died on or about the 13th day of October , 19 98 .
I represent that, to the best of my knowledge, the deceased has no pacemaker in his or her body.
DISPOSITION OF CREMATED REMAINS
I hereby direct Adirondack-Burlington Cremation Services to dispose of the remains as follows:
Mail to: Kidder Memorial Home
(Funeral Director or Family)
89 Grand Ave. , Swanton, Vermont 05488 (802) 868-3331
(Street—City —State— Zip Code)
Other Arrangements:
(Please Specify)
I certify that I have full power to give the above Authority to Cremate and to direct the above Disposition;and I agree to
protect, defend and save harmless Adirondack-Burlington Cremation Services and the Funeral Director from any and all
claims and demands for liabilities, losses and/or damages which may be made against them,or either of them,by reason of,or
connected`with,any action taken by them under the above Authority to Cremate and/or Disposition granted and directed by
me, whether such claims or demands are or are not groundless, false or fraudulent.
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Witness Sisnature of Relat( c or LesiVRep,
Guardian _
Funeral Director Relation to Deemed or Authority to Sian
89 Grand Ave. , Swanton, Vermont P.O. Box 246, Alburg, Vermont 05440
I
Address '- Address
October 13 1998 19—,..
Important: The Funeral Director should make adequate inquiries of the deceased's medical doctor and relatives and any
hospital involved to assure that deceased has no pacemaker implanted in his or her body. If any pacemaker was implanted,it
must be removed before the body is delivered for cremation.
.w tjk VWf.JG ll I IWI IL VI 1 IUI I1G 1 I 1\GAVUIl06A
Vital Records Service
PERMIT FOEiTHE DISPOSITION OF HUMAN REMAINS" PERMIT NUMBER-
"Name of Deceased Date of Death Fetal Death?'
No [
1 Cortland Vaughan Langworthy, Jr. 2.November 30,19983 _ Yes ❑
Place of Death(Hospital or Street No.)OR Interment(Cemetery) City,Town or Location of Death OR Interment County of Death OR Interment
Crawford Long Hospital Atlanta Fulton
4. 5. 6.
Name of Certifying Physician,Coroner or Medical Examiner Certifiers Address(Not Used For Disinterment/Reinterment)
(Not Used For Disinterment/Reinterment)
490 Peachtree St., NE, Suite 330-B
Z Finley Feinstein, M.D. s. Atlanta, GA 30308
Funeral Home Name and Address Funeral Home Lic.No.
Carl J. Movell & Son Funeral Home
s_. 20ff-Robinson. Rd.", Peachtree City, GA 30269 10. 1422.
Method of Disposition OR Gate of Disposition OR
Reinterment
Disinterment/
11. Cremation ❑ Donation ❑ Other ❑ Removal From State [11 Reinterment ❑ 12.
Name and Address of Disposition OR Reinterment Site Location of Disposition OR Reinterment Site
(County.City or State)
Pine View Cemetery Queensbury, New York
13. 14.
31-10-20.(a) The funeral director or person acting as such, or other person who first assumes custody of a dead body or
fetus shall obtain a disposition permit prior to-cremation or removal from the state of the body or fetus. A disposition permit:
may be msuM within the st local authorities.
Local lfilai Sig
natu Date Signed
15. 16.
December 1, 1998
Sodon*Parsm to Charge)-Signature , Date Signed
"7 18.
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