Fisher, Arthur ZO�v OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name S 14 F Case# 2�
Date Of Cremation_
Time Cremation Started 17 —� [J— � -A%
Time Cremation Completed
Type of Container
Remarks
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FROM SUZANNE NAROUFF PH3NE NO. : 928 524 2639 May. 23 2003 02:20PM P3 r
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" tower's DeOp4m of Inteodiotis"
Nurse of Decewed: sr2
Cremacbn: ,r! F' AtOx
(scheduled Date)
Mmur of Lliapogigort of Crernain
I�/ 7 gutw at I'l �_` ._ [ ) Returo to(Specify person to receive erewins)
[ ) Enlornbimnt at 1
t 1 Other(specify):
I hereby designate the DieposiOm of C ron2ains and ackpowledge receipt of a copy of=his farm.
wokaliar")' .P',
/ ( eUaanesuP Dedessifd}
1 e1�
( epbaao tvuthbar) .
"Cremalm vvtticlt sbWl not have been rlsiaed wfthk I"data;roan the dine of crmwflon may be dhposed of by;Obr
&m,In ibe fbllowi"muner of dbpwWou I
fr '
Muted Nome of Funcral Dino m sips v of PowAal DkwW Dale
at Underudw at Uodmpi w
TO BE COMPLETED FOLLOWINQr CPJZIATION AND DISPOSITION OF REMAINS
Cfamatldu:
(Actmi Dots) (Laoadoo of
Dispwit w of Cremwtts:
MGM—at apoddon)
(Lwadm)
(]Date)
Kt=or Pomm Maki ug AiIpesMan Dew —
I hereby acknowledge that on _
Done
I twk possesaton of the cremum pf
JAMS OF DgC6AS8p)
(SlGjNAlURE) (NAME O!PER.5.0N RSCE'V7fIV't3 CRL MAV6)
Whits copy tv taauly Up M lAtuat K aPSOMMt— WIPW oovS to N-W MOM—Pkk sajy to family upon,&yuaition
er zi-xev iarre
FR�lf1 SUZP11HE HRROUFF R-10HE NO. : 828 524 2639 May, 23 2003 02: 19PM P2
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TOWN OF QUEENSBURY
PtNE VIEW CEMETERY&CREMATORIUM
j Quaker Road,Queensbury,New York, 12e04
Phone(618)Crernatoriurn 745.4477 of no answer Cemetery 745-4416
AUTHORIZATION TO CREMATE
Tha undersigned regVests and authorizes Pine View Crematorium, in Acc orden-'a vrith and subject to Its
Rule and kogulat one t remate the remains of
(Name)
(street) cCk1f) (state) (Zip)
who died on
at. ILI jj Le(Piece) (Address)
Naa m and address of nearest relative or name of parson Authorizing cremation,
rGdC �. LolC• ieO4A Kc.i� �.
(Name) (Address)
Relationship to the deceased
Ntme of Funeral Horne
u
IMPORTANT:
I represent that to the test of my knowledge,the dd�0 sod has or has no peacemaker In his or her body.
(Cite
140
1 (;artily that I disposition
flee full the cower and authorLwUon to remated remains,that anyarrange For the pemfksl possesslongh ave either been r•m"d
orIm the disp trove of t
or gray be destroyed, and %gree to protect, defend and Save harmisas Pie View Cr9mStoRum hem an'1
end all alal!ns end demands for loss or damages, which may be made against them by reason of or
connected with the cremation of 5Ild remains as directed,whether such elalms or demands are or are not
wholly groundless,false or fraudulent
(Wbess) (Address)
( ignr —, of els i M 0r�- ql �pandAndres�) �
Stgned on this date. O
REMOVAL,TRANSIT AND BURIAL PERMIT Z 14 3 PERMIT NO. G DATE ISSUED
V,t-9 ReO12/18/98 STATE OF CONNECTICUT l p 'y I .T- 1,93
DEPARTMENT OF PUBLIC HEALTH
HARTFORD,CT 06134-0308
l
1. THIS PERMIT:a.Is sufficient for the removal of a body to any town and also for interment;b.must accompany body and c.must be given to person In charge of cemetery
and endorsed at bottom by the sexton who must then forward it to the registrar of the town where the cemetery is located.
2. THIS IS NOT a permit to cremate.For that,a Cremation Permit(VS-48)must be obtained in addition to this permit.
3. This form must be returned to the REGISTRAR of the Town where the cemetery is located.
PERMISSION IS GRANTED TO REMOVE/TRANSPORT/BURY THE BODY OF WHO DIED AT ON
�rfhur S- i 5 willvn Headoul S/aa /O 3
CAUSE OF DEATH
C v f L a.r atja c a rr t-s (-
TEMPORARY DISPOSITION(LOCATION,ADDRESS,CITY,STATE AND TELEPHONE NUMBER)If body placed in receiving vault,give date.
FI DISPOSITION(Nam nd address of cemetery or matory)
Inn iu<J r or &Iut—sour or
BURIAL PLOT SECTION NO. T NO. GRAVE NO. OTHER PLACE OF INTERMENT(Specify)
ISSUED TO(Name of Funeral Director or Embalmer) ADDRESS Q 4,ea 9 IF EMBALMER,LICENSE NO.
156
vl-o u c Tn Cl v� cv GT ! 8y
Certificates required by state statute have been SIGNED(Registrar of Vital Statistics TOWN OF TRANSIT PASTER
received and recorded.Body has been prepared
in accordance with the Public Health Code. 711n p YES p NO
THE BODY FO 11 THIS PERMIT WAS ISSUED WAS BURIED IN ABOVE NAMED DATE BODY BURIED
SEXTON'S ENDORSEMENT CEMETERY(Sexton's Signature)