Crossman, William rrO TVN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director F�
Name " � �,,M (� Q�j.'t�ffJl� Case #
Date of Cremation 70 _ R �}
Time Cremation Started ] 1 , -06 A /vim
Time Cremation Completed
Type of Container (�j�iZ�� ���,� � (��}y� ?� C' 1+,g
Remarks :
t4 B 0 f� t�Z
MC )V/5- 1D r 1 ra tc !9
TOWN OF QUEENSSURY ,
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 :
W iii iam C¢ozzman Naie
(Name) (Sex)
Biizzv.iiie Road, P. O. Box 176, Kydev.iiie, Vt. 05750
(Street) (City) (State) ( Zip Code)
who died on 19.th day of Decem9eiz 1999
at fl-iz Rez idence, P. 0. Box 776, llydev.i-tee, V.t. 05750
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased Soc.iai Caze Gl02ken
Name of Funeral Home Buz/ee Fuae2ai flome, fait Haven, Vt.
IMPORTANT:
I -repregent 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)
< < ,
(Sign ture of Relative or L 1 Rep. and Address)
Signed on this date: Decemge2 19 1999
No.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN fjODY
ti
Full name of decedent N11 Uizz iam
Decedent's address NiztU Neathe/t ('loan Calu dome,_ % C) Box 176, KUdey-Liie, V.t.
Date of death /sec. 19, 1999 Place of death fl.iztu Heathen cane Nome
Cause of death certified by Dn• 7homaz McConm.ick
Permission to cremate the body of this decedent at Pine View Cnemat on.ium
Quaken Road, Nwe Yonk
(Name and addrewM of Crrmator%)
has been requested by aamez Rug.in o/: DtLnz/ee Funeaai Nome
(Funeral Director)
Vermont F. D.
License No. 1030 119 Na. Main S.t , Faia N , )eri, V.t
(Addrewo 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 * Dec. 20, 1999 (Signed) // , Examiner
Address F (21 k`4
18 VSA SEC.5201 (b)