Colville, Jean ' rnWN OF n UEEV B U99y
PINE VIEW CEMETERYJ AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director rp D
Name TEp' rV b) c'o —yt Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed a 10
Type of C o n t a i n e r
Remarks :
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No.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
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Full name of decedent Nnz• lean Co ey-i iie
Decedent's address 4 Cedaa S vv.ly Friin fln„on, Vf_
Date of death Dec. 7• 1999—Place of death Re_2 Rp- i r rl v n ev_
Cause of death certified by Da. Eizeman
Permission to cremate the body of this decedent at Pine Vie C2emat zoy
Quakes Road, Queenzeuaa, New yolk
(Name and addrewM of Cremator%)
has been requested by _ aame.6 Aufl i.n o Du2lee Tune zai Rome
(Funeral Director)
Vermont F. D.
License No. 1030 119 No. Na-in St. , Faiz Raven, VCt
(AddreoM 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 gi (Signed) , Examiner
Address
18 VSA SEC.5201 (b) 1119
O�l!l T
i
TOWN OF QUEENSEURY
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 :
N,Tz. Jean W1iizon Coiviiie Temaie
(P:a m e) (Sex)
4 Ceda�z Stbzeet, tai/t Haven, Ve�zmont 05743
(Street) (City) (State) ( Zip Code)
who died on 7th day of Decemge�z 1999
at 4 Ceda2 St�zeet, fait Haven, Vt. 05743
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
.'1 0//t� P ee)1li/,-L -e_ - t��� ,���SS4114/-e Xa,�D, /./Vaeu1G1 �� vT
(Name) (Address)
Relationship to the deceased So xJ
Name of Funeral Home Du2lee funezai Home
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.
( ss) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date: Decemge2 8, 1999