Mapes, Robert TOWN OF QUEEN,5BU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director
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PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY PURSUANT TO NEW YORK STATE PUBLIC
HEALTH LAW SECTION 4145(2)(B)
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
Robert M. Mapes
2. DATE THE BODY WAS DELIVERED
December 2, 2003
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
Harold E. Moffitt, #03535
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
Regan & Denny Funeral Home
5. NAME OF PERSON Q/IIN CHARGE OF CEMETERY
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6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
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8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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:
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(Name) (Sex)
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(Street) (City) (State) (zip)
who died on 1 day of C. 20 03
at (::I,-, '= �Z'J� �--�- 1 \.(
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation: 9D
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(Name) (Address)
Relationship to the deceased JQt\1
Name of Funeral Home 12E��tr�! i:J�!!►f
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 groundless, false or fraudulent.
(Witness) (Address)
(Sign ure of Relative or Legal Rep. and Address))
Signed on this date: