French, Donna TOrTI/N OF QUEE-r 45BU Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY t
CREMATORIUM a -
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:
Donna Ann French Female
(Name) (Sex)
85 Elm Street Hudson Falls,NY 12839
(Street) (City) (State) (Zip Code)
who died on 24th day of November 2003
at Glens Falls Hospital 100 Park Street Glens Falls,NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Douglas French 85 Elm Street, Hudson Falls,NY 12839
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or as
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 not wholly groundless, false or fraudulent.
I
68 Main Street P.O.Box 67, Hudson Falls,NY 12839
(Witness) (Address)
(Signature of ative or Legal Rep. and Address)
Signed on this data:
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last
Sex
Donna Ann FRENCH
Date of Death Age If Veteran of U.S.Armed Forces, Female-
November 24,2003 58 War or Dates
Place of Death Hospital,Institution or
City,TWOMOMW Glens Falls Street Address Glens Falls Hospital
PManner of Death N Natural Cause O Accident Homicide [:]Suicide Ej Undetermined Pending
Circumstances Investigation
Medical Certifier Name
Title
C Farhana Kama],AID
Address
---F
Death Certificate Filed
District Number Register Number
City, Glens Falls 5601
Date Cemetery or Crematory
❑Burial November 26,2003 Pine View Crematorium
Address
ECremation
In of Queensbua,NY 12804
Date Place Removed
z
0 Removal and/or Held
— and/or Address
Hold
0 Date Point of
JM QTransportation ---7Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
00
Name of Funeral Home Carleton Funeral Home 284
Inc-
Address
68 Main Street P.O.Box 67, Htidson Falls,NY 12839
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 described above as Indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
W Date of Disposition Place of Disposition
2 (address)
LLJ
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
z (please print)
Signature Title
DOH-1555(10/89)p. 1 of 2 VS-61
Body Delivered on V- P6 20
For 144. k.'4 Representing
(Name) (Name)
VI Cemetery, Inc. Carleton Funer_al Home, Inc.
C-V-'e "- License No. 7 Y3