Dumas, Kirsten TOWN OF QUEENSBURY
Pine Virtu Cemetery and Cremotonum
21 Qunker Rood, Queensbury, NY. 12804.5902
(518) 745.4476 (5t8) 745.4477
h(rp iiwNv%v queensbury net
Funeral Director: 1h
Name of Deceased: _ r����` 1= �'` '►Q 1-1 l-- ✓fir S
Case Number:
Date of Cremation:
Retort: D—T , l fi45- P/V\-)
Time Cremation Started:
Time Cremation Completed: 11
Type of Container: � �� ti3 y ►�l`ZJ �(► � N I d� l� ��/�I
Remarks:
Mo 110)
Horne of Nnturnl Benuty .. A Goof Plnie to Live
TOWN OF QUEENSBURY
IVIEW 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:
(Name) (Sex)
01:4,7
(Street) (City) (State) (zip)
who died on day of �TQ &U 20 y�_
at
(Place) U (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) }(Address)
Relationship to the deceased h u,s bp'�C�
Name of Funeral Home erd_� S-Q"
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
w olly groundless, false or fraudulent.
0-e c,:r
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address))
Signed on this date: /as-
STATE OF VERMOI `4AGENCY OF HUMAN SERVICES-DEPARTTI1ENT OF HEALTH
No.
It OFFICE10 THE CHIEF MEDICAL EXAMINER
MEDICAL EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
ih
Full name of decedent %
Decedent's address
Date of death z1 l Town of death Jck A�tN, 1/L w wy
Cause of death certified by v.
Permission to cremate the body of this decedent attV£ Cr'-2 W.1a.TZ�
(Name and address e atory) n
has been requested by »tE L. f.D 1 �&;Inu
�UYI�Y�tX
(Name and address of Funeral Director representatixi, r person requestin the permit)
Vermont Funeral Director License Number:
Being sufficiently informed as to the causes and circumstances of the death of the above
described decedent,permission is hereby granted to cremate the body as requested.
Date Y (Signed) SO,Medical Examiner
Address L/ / &V LC
18 VSA SEC.5201(b)
DISTRIBL*ION:White Original:Crematory via Funeral Home or person requesting permit Yellow:Funeral Home Pink: Local M.E. Goldenrod:OCME
MEDICAL EXAMINER'S CREMATION PERMIT:PURPOSE AND PROCEDURE
As outlined in Vermont Statute Title 18,Section 5201,Medical Examiners To reach a Local Medical Examiner to sign a cremation permit:888-552-2952
(Chief,Deputy,Regional,and Assistant)must issue permits for bodies of
persons who die in Vermont and are to be cremated.The OCME will Points to Remember:
maintain a list of Medical Examiners that are authorized to perform this duty A$10.00 fee for reviewing the d certificate and signing the permit is statutorily
for distribution to funeral directors and crematories.The list will be mandated and paid directly to the Medical Examiner by the funeral director or the
distributed a minimum of once per year to funeral directors,crematories and person requesting the permit.
medical examiners,and updated as necessary.Only individuals appearing -
on this list are authorized to issue cremation permits. All death certificate amendments res#ing from the cremation permit review
process will be issued by the OCME.
The purpose of having a medical examiner review a death certificate prior to
cremation is to ensure that questions about the certification of death are Cremation permits are never to be pre-signed.
addressed before irrevocable disposition of the remains occurs.Following
cremation,there is no way to examine a body.Therefore,the medical Cremation permits are now printed in four-part format.The goldenrod copy is for
examiner must be satisfied that the cause and manner of death are correct the local Medical Examiner to retain.The pink copy is for the funeral director or
and that no further examination or judicial inquiry is warranted before a the person requesting the permit to retain.The yellow copy is mailed to the OCME.
cremation is authorized. The white original is to be filed at the crematory.
The funeral director or other party requesting the cremation permit is If there are any concerns or questions regarding the certification of death,
required to present a copy of the death certificate to the Medical Examiner. cremation will not be authorized until they are resolved.Any questions about
Medical Examiners are required to make personal inquiry into the cause and signing a cremation permit should be directed to the OCME. g
manner of death.A review of an accurately completed death certificate may
be all that is necessary. OFFICE OF THE CHIEF MEDICAL EXAMINER
111 Colchester Avenue,Baird 1
If the cause and/or manner of death as it appears on the death certificate are Burlington VT 05401
not accurate or not etiologically specific,the Medical Examiner must initiate Voice:(802)863-7320
an investigation prior to issuing the cremation permit. FAX:(802)863-7265