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Lennox, Frederick TOWN OF QUEEN4,5BU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 0dJy/y Name 'K k /YlYaX Case # ZY/ Date of Cremation Time Cremation Started Time Cremation Completed / / i�{�i9IM r Type of Container 4OOP ��/ � 1�,piG/ ©j� Remarks : M :H '-;E'=;ElUlili F.H. F';_E 4- . 7 Vermont Cremation Service I Box 957 213 West Main Street Bennington, Vermont 05201 (802) 442 9585 or in Vermont 1-800-244-9585 CREMATION AUTHORIZATION STATE _. .._._ _-_- --..--.._ -- -_----------_-_--- _._.._-- Cremation Number COUNTY OF -.... - ---- --- -- - - -- - Cremation Date - - -- - —-— ----- ---------- (tor crernanon use only) IDENTIFICATION The undersigned authorizes Vermont Cremation Service ("Crematory"), in accordance with and subject to its Rules and Regulations, and any applicable federal, state and/or local laws or regulations to cremate 0 who died a2 X _._. .._ D N - -- on the _..-- --___--- --- ---- -- -�---- day of �']�� tt3.gOdl_ at the age _� _- years and agrees to be responsible for and pay all charges incurred with respect to this authorization. The Funeral Director in Charge Is _-_hQ_6_e,JL+_S _C_hA4f,_ (Funeral Director) I Further state the death 'D was U was not due to infectious or contagious disease. I understand that if I do not notify the Crematory about a death by infectious disease, that I will be liable for any damages to the Crematory or injury to Crematory personnel As the authorizing agent for the cremation of said deceased __. _-_---_-_____,- I have O identified rJ authorized (as my agent to identify) the deceased as . I hereby certify that I am related to the deceased as _ or otherwise serve in the capacity of and that I have the right to authorize the cremation and dispcsition of the cremated person DISPOSITION it is requested that the following disposition be made of the person, D Place the cremated person in Cemetery - fees furnished upon request Q Delivery to _. Fol;owing cremation the undersigned hereby authorizes Crematory to deliver Via Registered mail and agrees to assume all liability for any damages that may arise from any cause growing out of said delivery and to indemnify and hold harmless the Cremators and the Funeral Director from any ari claims related to said shipment. To be called for by ��.-=---�-���------------------- ---- -- --------------- I understand that due to the nature of the cremation process any valuable material, including dental gold, will either be destroyed or not be recoverable Any personal possessions accordingly have either been rerr.oved or may be destroyed "if the container or any other portion thereof is not suitable for cremation. Crematory may require the,person be rempvgd to suitable container" I understand that cremated persons are bone fragments, which will be reduced in size and.plK.e4in.an urn Urns provided by Crematory are sufficient in size for all cremated persons In the event the capacity of the urn I select- ed elsewhere is less than the amount of the cremated person, the Crematory is hereby authorized to return said excess of the cremated person in a temporary container I further agree that I will indemnify and hold harmless the Crematory and Funeral director, their officers and employees from liability, costs, expenses, or claims from this authorization LIFE SUSTAINING DEVICES I further state that the deceased has not had a heart pacemaker implanted, radiation producing implant device, nor any other life sustaining device that could be explosive. If such a device exists, i have instructed the funeral director or others to remove it before cremation 1 also agree that in the event of my failure to notify the funeral director or any others