Perry, John �0WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director D()R EGE
Name -�tjh,q Case #--6?vto
Date of Cremation 2
Time Cremation Started
Time Cremation Completed /►/�
Type of Container ('p.-N� \30A-vrD C-OOF— Lj 614,j
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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 :
Mr . John Joseph Perry Male
(Name) (Sex)
29 Grape Street , Fair Haven, Vermont 05743
(Street) (City) (State) ( Zip Code)
who died on 26th. day of December 19 99
at 29 Grape Street , Fair Haven, Vt . ( His Residence)
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mrs . Carolyn Perry 29 Grape Street , Fair Haven, Vt . 05743
(Name) (Address)
Relationship to the deceased Wife
I
Name of Funeral Home Durfee Funeral Home of Fair Haven, Vt .
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker 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 Rela ve or Legal Rep. and Address)
Signed on this date: December 26, 1999
I
. V
No.
STATE OF VERMONT `,
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent John Joseph Perry
Decedent's address 29 Grape Street , Fair Haven, Vermont 05743
Dateofdeath Dec. 26, 1999 Placeofdeath Above address (His Residence)
Cause of death certified by Dr . Robert SRonzo, Glen Falls , N.Y.
Permission to cremate the body of this decedent at Pine View Crematorium
Quaker Road, Queensbury, New York
(Name and addrerr of Crematon)
has been requested by James Aub i n o f" Du r f ee Funeral Home
(Funeral Director)
Vermont F. D. 1030 119 No. Main St . , Fair Haven, Vt . 05743
License No.
(Addrere 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
Addreokf
18 VSA SEC.5201 (b)