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Stephens, Conley 2"O OF QUEEN5BUJKy PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4-476 (518) 745-4477 Funeral Director 1ycck kkp-- 1, aTe Cd14W. 9'10 he. 4 Case„ _aI e OF Cremation Cremation Started "� � �� Am .gyp Cremation Completed ?e of ContainerCil+YLD 13,0 rj( 2 MLt,�p j AA �e�arks 5� �� e F � Vermont Cremation Service Box 957 213 West Main Street Bennington, Vermont 05201 • (802) 442-9585 or in Vermont 1-800-244-9585 CREMATION AUTHORIZATION STATE P� k0delt" Cremation Number 0 COUNTY OF rN . Cremation Date O (for cremation use only) The undersigned authorizes Vermont Cremation Service ("Crematory"), in accordance with and subject to its Rules and Regulations, to cr mate the remains of ,/ !' who died at uePA)C/�u 'R' 41 on theme _day of at the age of years and agrees tog e respor�sib�f�r ar)d pay charges /inc/u'rre(with respect to this authorization. The Funeral Director in Charge is , P!A/ � Funeral Director). I Further state the death ❑ was kP was not due to infectious or contagious disease. I undersfand that if I do not notify the Crematory about a death by infectious disease, that I will be liable for any dam- ages to the Crematory or injury to Crematory personnel. It is requested that the following disposition be made of the remains: ❑ Place the cremated remains in Cemetery-fees furnished upon request. ❑ Delivery to The undersigned hereby authorizes Crematory to deliver the cremat- ed remains Via Registered mail and agrees to assume all liability for any damages that may arise from any cause growing out of said delivery and to indemnify and hold harmless the Crematory and the Funeral Director from any and all claims related to said shipment. ❑ To be called for by I hereby certify that I am related to the deceased as the deceased died of natural causes, and I have the right to authorize this cremation and the disposition of the cremated remains. I understand that due to the nature of the cremation process any valuable material, including dental gold, will either be destroyed or not be recoverable. Any personal possessions accordingly have either been removed or may be destroyed. *If the container or any portion thereof is not suitable for cremation, Crematory may require the remains be removed to a suitable container.* I under- stand that cremated remains are bone fragments, which will be reduced in size and placed in an urn. Urns provided by Crematory are sufficient in size for all cremated remains. In the event the capacity of the urn I selected elsewhere is less than the amount of the cremated remains, Crematory is hereby authorized to return said excess cremated remains in a temporary container, I further agree that I will indemnify and hold harmless the Crematory and Funeral Director, their officers and employees from liability, costs, expenses, or claims resulting from this authorization. I further state that the deceased has not had a heart pacemaker implanted, radiation producing implant device nor any other life sustaining device that could be explosive. If such a device exists, I have instructed the funeral director or oth- ers to remove it before cremation. I also agree that in the event of my failure to notify the funeral director or any others responsible for the removal of such device, I will be liable for any damages to the Crematory or injury to Crematory per- sonnel. Pre Need 50 At Need ❑ igned: If Pre-arranged, signature of J p,�` Address: �O6 �e/fib /�/ � ,/.✓� (Relation) City: ri�Clf as responsible agent of the deceased. Signature State/Province: �0�9� Zip: Telephone: Date: p8/23/20e@ 1)J: 17 516-r4 -447, f 0 rarac. IjX. (� TOWN Or QUEENS13URY PINE VIEW CEMETERY B CREMATORIUM Quaker(toad, Oueensbury, New York 12804 Phone(5181 Crematorium 745-4477 (it no answer) i Cemetery 745-4476 AUtHORIlATION TO CREMA7 L: i The undersigned requests and autl,�rizes Pine View Crematorium, in accordance with and subject to its Rules and Regula!iono to cremate the remains of. (tf�,ME i (SFX) wo luo���if`�.✓ /5ooricLl�4` /(1y /.r�9'd (STREET") (CI 1') (STATF) (ZIP UODE) who died cn_ _ �J _ I _day of —4 ;G ----- 200 at�d 6 (PLACE, (A 'bRESS) f Narr,e and address W nearest living�elative or name of person euthorizaig cremation: I Relationshlq to deceased Name of Funeral Hcme_�������/L��--r_��/CST___ IMPORTANT I represent that to the best of my kn ,n'iedge, the deceased tins or f_2s fro pacemaker in his or tier body (GIi UE ONE) I I certify that I have the full ;rower ani],authorization to arrange tar the cremation of the remains and to direct the d+scoosation of the copmeted remains, that any perional possessions have either been rrmoved or r"a�be destroyecf.iersd agree to protect, defend arrC save harmless Pitie Vio'A Crematorium freln any and all clalni and demands for loss or:ia riages which may be made ayalns!thern by reason o'or connelted with the cremation of said remains as directed,whelt;er sucl �I ms or dr, ands are of are rio'wholly groundless, false ur f1oWulent (WITNeSS) — qr✓R 5sj a (SIGNATURE CN Flu' ✓ /Q/R LF-GAI Rl_ . N AD )f2ESS) Signed on this date._-�� 4`T ^ i I i 04/13/2004 10:46 5188543600 MCCLELLAN PAGE 01 73/23/2t 00 i u i (TOWN Ur=QUEENSBURY ' PINE VIEW CEMETERY II S CnEMATORIUM Quaker shoed;©ueensbury, New York 12604 Phone(5161'Crernatoriurn 745-4477 (!(no answer) Comelfiry 745-4476 I : AUtHORIZATION TO GF EMAI E The undersigned r0uesls and.Wt, izes Pine View Crematorium,in accordance w:16 erid subjpcl to its Rues aho RegufatiGn to cremate the remains of; triAanE (SFX) II AJI (STREET)- (STATP) (ZIP CODE) li who died on da of i Z. at_.76 /a.v—ALILA ��SX�/ _r� (PLACC- pb j msS) / • i i Nance end address 61 nearea;t I(ving etative or name of person eulhoriting cremation. flt:lationahlp to deceased Name of Funeral Hcrna • - � ---� • t i IMPORTANT I repi..asenr that to the best o1 My kn Nledga, the deceased ha,or has rIQ pncenraker ;n big of hey body. (GIRCI.E (ME) � . I I I Certify that I have the full IPU vif ens suftrizabon to arrenfae tqr the cremat a of tl reriiai.�s and to Cirect the dtsposittorr Of the ci�m?tvd remains,that din f Per±anal po3see3stons hPvyx either been rprnoveo yr ►+ay pe'0sbdyed.ia(,d agree to protect,delend mi'd savor harmless P1,10 VieR Crematorium le-orn. oily W.10-41 elalm .and demands for loss or da:riages which iney De*d9 ag4inst them by reRson of or Bonne led with the cremation of said rerriainv os directed.%Oielher s?0 .c1eqrns or�i+i. ndi•are ter are iia hotly groundless,false or traudu(eY�l. (WITtVESS) GRESS) jSt(;!1P4TUt?>=. :Ft. 1' UR I,FG.4t Ft_ .AND iIiFSS) r Signed vn this date: j I i I NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Conley C.Stephens M Date of Death Age If Veteran of U.S. Armed Forces, April 12, 2004 67 War or Dates YES 57-63 Place of Death Hospital, Institution or City, Town or Villaca• of Queensbury Street Address 26 Dorlon Drive Manner of Death Natural Cause Accident Homicide Suicide Undetermined El Pending Circumstances Investigation Medical Certifier Name Title Wiliam A. Tedesco MD AddTess Pine St. lens Falls, New York Death Certificate Filed Tn. of Queensbury District Number Register Number City, Town or Village 1� Date Cemetery or Crematory ❑ Burial April 14, 2004 Pineview Crematory Address Cremation Date Place Removed 0 ❑ Removal and/or Held -- and/or Address Fh Hold Q Date Point of Q Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date. Cemetery Address Permit Issued to McClellan Funeral Service Registration Number Name of Funeral Home 01 208 Address East Broadway Salem NY 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 rem 'ns described abb a as indicated. Date Issued 4-1 4-0 4 Registrar of Vital Statistics �. (signature) District Numbers? Place Tn. of Queensbury, NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Place of Disposition f/N Vl-�C / CAC-Al 14y"01 "eq .2 (address) w W M (se tion) (lot num er) (grave number) 0 Name of Sexton or Person in Charge of Premises k&-;X? g (please print) Signature Title 4o IC (over) DOH-1555 (9/98)