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Smith, Judith "WN OF QUEEVBU�Ky PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, :NEW YORK 12804 (518) 745-4476 (518) 745-4477 < Funeral Director ,�,`,(', Name !! t ��l / � Case # Date of Cremation - - <J� Time Cremation Started Time Cremation Completed 31�56 Jet AD Type of Container G'h `<j G/}, '©/� 72Zc- gam Remarks : l r� Poo 11�7"M , P/14 , i i i TOWN OF QUEENSBURY -PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone(518) Crematorium 7454477 (if no answer) Cemetery 7454476 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 ) (SEX) (STREET) (CITY) ( ATE) ZIP CODE) who died on day of 2L_- 20 0 0 at (PLACE) (ADDRESS) x me and ad ss`of nearest living relative or na'giel of person authorizing cremation: Relationship to deceased Name of Funeral Home IMPORTANT I represent that to the best of my knowledge, the deceased has or as n p cemaker 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 agrde 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) I I (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date:�` Z — oZ o u 'J i i i NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Judith E Smith Female Date of Death Age If Veteran of U.S. Armed Forces, August 1 2000 65 War or Dates Place of Death Hospital, Institution or City, Town, or Village Glens Falls Street Add reSSGlens Falls Hospital Manner of Death x❑ Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑ Undetermined ❑ Pending Circumstances Investi ation Medical Certifier Name Title Dr. James North M.D. Dr. Address Broad Street, Glens Fallls 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls Date Cemetery or Crematory ❑ Burial August 4 2000 Pine View Cemetery Address ERICremation uaker Road Oueensbury, NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 101234 Address 136 Main St. , South Glens Falls, NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains cribed above as indicated. Date Issued C)Q Registrar of Vital Statistics (signature) District NumberCool Place Glens Falls,New York I certify that the remains of the decedent identified above were dispose_d/o'f in accordance with this permit on:: Date of Disposition r Place of Disposition ��/1f. (address) (section) (lot number) rave number) Name of Sexton Person in harge of Prem. es (please print) t Signature Title