Loading...
King, Sheila TORN OF QUEEMSB -WY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director X, /� / - Name . "� � //(Y C a s e # Date of Cremation �7O pp�� Time Cremation Started � Time Cremation Completed J-►�9n1 IV 1 - � Type of Container Remarks : r LL i i i i Vermont Cremation Service Box 957 213 West Main Street Bennington, Vermont 05201 (802) 442-9585 or in Vermont 1-800-244-9585 CREMATION AUTHORIZATION STATE Vermont Cremation Number COUNTY OF Bennington Cremation Date (for cremation use only) IDENTIFICATION The undersigned authorizes Vermont Cremation Service ("Crematory"), in accordance with and subject to its Rules and Regulations, and any applicable federal, state and/or local laws or regulations to cremate ShLeila D. Kiny who died at Benn. , VT on the 11 day of October 19 98 at the age 55 years and agrees to be responsible for and pay all charges incurred with respect to this authorization. The Funeral Director in Charge is E.P.Mahar & Son (Funeral Director). I Further state the death ❑ was j M was not due to infectious or contagious disease. I understand that if I do not notify the Crematory about a death by infectious disease, that I will be liable for any damages to the Crematory or injury to Crematory personnel. As the authorizing agent for the cremation of said deceased Sheila D. King I I have identified ❑ authorized (as my agent to identify) the deceased as Sheila D. King I hereby certify that I am related to the deceased as Daughter , or otherwise serve in the capacity of and that I have the right to authorize the cremation and disposition of the cremated person. t_ DISPOSITION It is requested that the following disposition be made of the person: ❑ Place the cremated person in Cemetery-fees furnished upon request. ❑ Delivery to 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 E. P. Mahar & Son, Inc. j 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 j 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 j rccnnnciKin fnr fho romnval of ciirh riavira I will ha linhia for anv rfamaoes to the Crematory or iniury to the Crematory No. STATE,OF VERMONT EXAMINER'S PERMIT'CO CREMATE A DEAD HUMAN BODY Full name of decedent Sheila D. King Decedent's address RR 1 , Box 506, Pratt Rd. , Pownal, VT 05260 Date of death 10/11/98 Place of death Benn. , VT Cause of death certified by Dr. Edd Lyon Permission to cremate the body of this decedent at Vermont Cremation Service, 213 W. Main St. , Benn. , VT 05201 (Name and address of Cremalorc) has been requested by _ E• P. Mahar & Son, Inc. (Funeral Director) Vermont F. D. License No. 17 628 Main St. , Benn. , VT 05201 (Address of Funeral Director) 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 (Signed) , Examiner Address 18 VSA SEC.5201(b) Verbal permission received with written authorization to follow.