Kahwajy, Mitchell L
7O`WN OF QUEEVBUWy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director , 1
Name Case #
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Date of Crematicn — �,✓ Q
Time Cremation Started1
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Time Cremation Completed
Type of Container
Remarks :
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rmont Cremation Service
Box 957
213 West Main Street
Bennington, Vermont 05201
2) 442-9585 or in Vermont 1-800-244-9585
;EMATION AUTHORIZATION
/ Cremation Number
Cremation Date 6JO L4—
(for cremation use only)
IDENTIFICATION
The undersigned authorizes Vermont Cremation Service ("Crematory"), in accordance with and subject to its Rules and
/R�egulations,/n and any (applicable federal, state and/or local laws or regulations to cremate
1v1:tChcJ1 fiAl eh KE ►1w1t`1*who died atC2e5c )UuR? j14q HoMeon the /0 '
day of Dc-7D h e i2 19 at the age 96 years and agrees to be responsible for and pay all charges
incurred with respect to this authorization. tL-0
//
The Funeral Director in Charge is , P/Pw G. Gr6)t� (Funeral Director). I Further state the death ❑ was
N was not due to infoctiotls or contagions disomo, I m1dor'AtmW Ih:At 111 Flu not wlify th@ Of@I11atofy about R OOR111 by
infectious disease, that I will be liable for any damages to the Crematory or injuryn to Crematory personnel.
lyl�As the authorizing agent for the cremation of said deceased t
LL e I f 11 Wi f n, uy> ve ❑ identified
authorized (as rri gent to identify) the deceased as - ereby
certify that I am related to the deceased as c , or otherwise serve in the 4acity of
L ��and that I have the right to auk orize the cremation and disposition of the cremated person.
DISPOSITION
It is requested that the following disposition be made of the person:
❑ Place the cremated person in _ Cemetery-fees furnished upon request.
TO Delivery to el Pw (c , G r'h 1y e Following cremation the undersigned hereby authorizes Crematory
to deliver Via Registered mail and agrees to assume all liability for any damages that may arise from any cause growing
out of said delivery and to indemnify and hold harmless the Crematory and the Funeral Director from any and all claims
related to said shipment.
❑ To be called for by
I understand that due to the nature of the cremation process any valuable material, including dental gold, will either be
destroyed or not be recoverable. Any personal possessions accordingly have either been removed or may be destroyed. "if
the container or any other portion thereof is not suitable for cremation, Crematory may require the person be removed to
suitable container." I understand that cremated persons are bone fragments, which will be reduced in size and placed in an
urn. Urns provided by Crematory are sufficient in size for all cremated persons. In the event the capacity of the urn I select-
ed elsewhere is less than the amount of the cremated person, the Crematory is hereby authorized to return said excess of
the cremated person in a temporary container. I further agree that I will indemnify and hold harmless the Crematory and
Funeral director, their officers and employees from liability, costs, expenses,or claims from this authorization.
LIFE SUSTAINING DEVICES
I further state that the deceased has not had a heart pacemaker implanted, radiation producing implant device, nor any
other life sustaining device that could be explosive. If such a device exists, I have instructed the funeral director or others
to remove it before cremation. I also agree that in the event of my failure to notify the funeral director or any others
recnnncihle fnr the remnval of Giirh rfevire. I will he liable for anv damages to the Crematory or iniury to the Crematory