Ellis, Raymond TOWN OF QUEEN
.s5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
t
Funeral Director
Name 4j, 0 �L'f ' Case #
Date of Cremation
r
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
A141,14
Ala Z46710 C) a-/!/\
14A,
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 :
(Na te) �- (Sex)
(Street) (City) (State) ( Zip Code)
who died on 4 day of LL,1-n/1 19 cjc(
at SPC,-E,2 �ZS��1Cs �DME 5 �"".�J c�L+ ST .
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation: (� (� (4
( e) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I re rese t 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) f (Address)
(Signat re Relative or Legal Rep. and Address )
Signed on this date:
' No.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent Raymond Azthua Miz
Decedent's address 28 P/to,,pec.t Staee.t Tail Raven, Vt.
Date of death 121411999 Place of death Sage.¢' ,6 Nu zzing Rome
Cause of death certified by Dn• l7.echaei Scovne2
Permission to cremate the body of this decedent at Pine View Caemat o zium
(,luakea /Road, New Yolk
(Name and addreow of Crematory)
has been requested by - aamez ,4u&in of Du2yeee fune2a e Rome
(Funeral Director)
Vermont F. D.
License No. 1030 119 Non h Na-in St. , iaia Raven, V7 05743
(Addrewr 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 cremat o y as requested.
Date De cem 9 ea 6, 1999 (Signed) ' Examiner
Address
18 VSA SEC.5201 (b)