VanLoan, Gene ZO`1 N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directori ��-►4N
Name &f hI y- �=-1 'y 1 /�-� _Case# 1p ��-
Date Of Cremation
Time Cremation Started- P-v(,
Time Cremation Completed 3 r Q 0 V
Type of Container Nx, AA)A,�T4 i ?
Remarks U 6°,Axzd d
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KAREN GILBERTSON
CORONER
3715 N. Newville Road ��sTATEo�
Janesville, WI 53545
Telephone: (608) 757-5908 2°
Fax: (608) 757-5470
kareng@co.rock.wi.us
OFFICE OF THE CORONER
Permission to Cremate
Case Number
fDrn6t,,�' VOm-- Loa-.^-
Name o eceased:
Address: ` �ey' �o � jo,^� , t,/ �� S�
18reet City, State Zi
Age: Date of Birth: /� a �9 J�a Date of Death: 3-- 6 3
Time of Death: ` AM Date Death Rec rd Signed: 3 — 12 — a3
Death Record Certifier: L MD / Coroner
Cause of Death: ac t-c
Attending Physician: /Same as certi ier
Funeral Director: 5'�r'k`1-Pit C
Person Requesting Cremation: Gh u-J n S- rq
Address:
Street City, State Zip
Telephone: 'J� / ` q� 3 Relationship to Deceased:
Additional Information:
This is to certify that I have viewed the body and made personal inquiry into the cause and manner of the death
of the decedent here named in accordance with s979.10 of Wisconsin Statutes. I am of the opinion that no
further examination of judicial injury concerning the same decedent is necessary and that permission to
cremate is hereby authorized after.
1,2 a pm
Ho r ' Month Day Year
Issued: 3 rjf-,fj -
Date Sin re and itle
***"* This permit certificate does not override the wishes of the Next of Kin
regarding the final disposition of the remains.
1
TOWN OF QUEENSBURY
PINE VIEW CEMETERY &CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone (518) Crematorium 745-4477 of 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:
(Name) (Sex)
1V'06 f d2rlt6-'w' jolt Wis. 6 3�6-q J
(Street) (City) (State) (zip)
l
who died on day of 1V1(t-1Z9GA} 20c_
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
,4nt r�aLS a U�x �,��r� �7��5� �02� d2i(!L'� �� J,+(
(Name) (Address)
Relationph)p.to the deceased vie l 1
Name of Funeral Home RJ +�^��1�7
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 grou dless, fall or fraudulent.
(Witness) (Address)
a—
(Signature of Relative or Legal Rep. and Address))
Signed on this date: c3J/4