Cross,Marilyn �O%N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name O `Cx Case # (�
Date of Cremation C( 9
Time Cremation Started ' ,'�j A M
Time Cremation Completed ) I . P"/ l
Type of Container G'rs'-1za j�r�-Cz—� cwt 1 0
Remarks : j'p'" 't C
M 4 k' R NZ--N2 ot\�
Aav
(0 0
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 :
►�AQx-
(Name) (Sex)
(Street) (City) (State) (Zip Code)
who died on 1) / `~ day of I3F2
at Q(-ATLII-v/� KEC�rc��11L_ ! / ►E,�rcA�_ ��iy%E�
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
op. 2��C-2 C2c�ss
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: r2 14A AEA J
I represent that to the best of my knowledge, the deceased has or j
<EEEfs no pacemaze 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 j
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 Relative or Legal Rep. and Address) CjS_ 7 3 �
Signed on this date: C) C-C E,- nf3E /3, 1
I
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent Maz. Maaiiyn Ann C2ozz
Decedent's address 216 P/iozpect Point Road, Bomozeen, Vt. 05732
Date of death Decemgaa 12, 19 Wace of death i2ut.gand Re yiona.e Medicai Centel
Cause of death certified by Da. C.tzemaa
Permission to cremate the body of this decedent at Pine View Caemat oay
Quakea Road, Queenzga/L a, Nq 12804
(Name and addrrwe of Cremator%)
has been requested by B2.i-an Cons.tani n,4 fho DuaZee Tanonn4 Hnmo
(Funeral Director)
Vermont F. D. 1174 119 Noath Main St. , fai.,z haven, V 7 05743
License No.
(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 cremate th ody as requested.
Date ' Decemge2 13, 1999 (Signed) , Examiner
Address �v
18 VSA SEC.5201 (b) pti c.. "K j L� Z-✓