Lapell, Winston �O�v OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4-477
Funeral Director "
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Roberts-A U' bin Funeral Horne
266 Men Ave.
P.O.Box Is 1
Poultuy,VT 05764
902-297-5511
FAX COVER FETTER
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Company Name
Fax To Number
From __ Roberts-Aubin Funeral Home
Fax Number --
Date —Time
Total pages including this cover sheet
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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
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2. DATE THE BODY WAS DELIVERED
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3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENT-- BY FUNERAL DIRECTOR OR UNDERTAKER
5. NAME OF PERSON IN CHARGE OF CEMETERY
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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91*01 Road.Queer",Nvw York 1M
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