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Madison, Stephen TOWN OF QUEENSBURY Pine View Cemetery and Crematorium 21 Qunker Rond, Queensbury, NY. 1 2804-5 902 (518) 745.4476 (518) 745.4477 h(cp:iiw\vNv.queensbury.net Funeral Director: 1` I Name of Deceased: P r�M� /Ih Case Number: 2, Date of Cremation: � Retort:;T— o _c I Time Cremation Started: Time Cremation Completed: .o -11;?�_ Type of Container: � ►1�{; I Remarks: all 2 !to Home of Nnturnl Benuty ... A Good Plnce to Live "" Jul-04-05 14: 51 P_O1 JUL-05-2005 03 :11 fill P.01 t f� TOWN Ol OUEENSIMNI PINE VIEW CEMETEP a CREMATORIUM Quaker R09d. OUeensaury, New Ya+x 12804 Plicne(518) Crematorium 7454w it no answer) Comelery 745•4476 AUTrtOR1ZATION TO CREIkATE Th4 .irkders�goed requests and sulno(ises Pine View CrCma7G•1,Im. In arrordance with and suOteC: toll Rules and RequletlEm:tb cramlile the remains of; ;SEX) 62 r r (S1REET) (Cl' ) is AFE) (ZIP CODE) wro dted Gn 1 day of ._..)�h-►e-.. 2C p (PLACE) (AC►QFtESS1 . Na Me end iddress of nea est living relative or name of peg' in author,zong Cremation. AL Relotionship to deceased__ ' Narye of F'l,neral�tOfRa.� � erc I LL..era) r. J++9 . 1M DRTA tT I re resent that to the be!$, of my Knowledge, the deceasedfiAl 0 s no paciarrink r; his or Pity b04/- (Ctf.CLE ONE) l c -tify that I have the full power and authorization to array+ a for the cremation of the rernains and ? to rest the Msposition of the crometed remains. that any t r4onal possessions have either been re) aved o-may be desircyee, and spree to prOtUt. defor- 4,10 Save harmless Pine view Cr matoriti m from any awl all claims and demands for loss it damages which may be made ag M them by reason 01 Or oortnened with the cremolJorr r said remains as directed. whetner s4 iTiC)airivir demands are or are gat wholly groundless. Ise or fraudulent. ° i (I�tTNE $) (A17DR SS) 4 '7 Y ' ' TUR C F RE L P A ) E S fi4 ''1� 4r this dill: ' — Kansas Department of Health and Environment,Office of Vital Statistics 2 `7 ti 1000 SW Jackson,Suite 120 South,Topeka,Kansas 66612-2221 = (785)296-1426 Coroner's Permit to Cremate a Dead Body Full name of decedent: STEPHEN ZANE MADISON Decedent's address: 6786-6 Burnside Lp. Ft. Riley, KS 66442 Date of death: 6 / 29 / 05 Place of death: Irwin Army Community Hospital, Ft. Riley, KS Cause of death certified by: see attachment Permission is hereby requested to cremate the body of this decedent at: (name and address of crematory) Pine View Crematory, Queens Bury, New York Permission requested by: (name of funeral director) Sharon Kurtze 1868 Manhattan, KS 66502 funeral director's license number funeral director's address Being sufficiently informed as to the causes and circumstances of the death of the above-named decedent, permission is hereby granted to cremate the body as requested. Date: /—� / ©� �� N coroneP`s signature County of: 4ILr,�L4 (See reverse side for instructions.) VS 221 rev 11-2001 Instructions for Using and Completing the Coroner's Permit to Cremate a Dead Body 1. A dead body cannot be cremated without this permit. This pertains to any death that occurs in the State of Kansas. 2. The funeral director is to obtain permission to cremate from the coroner of the district or county where the cause of death occurred. 3. In the case of out-of-state disposition, this permit must be attached to the white copy of the Out-of State Transit Permit that accompanies the body out of state. 4. In the case of out-of-state disposition, the Kansas licensed funeral director shall not issue an Out-of-State Transit Permit when the body is to be cremated unless the funeral director has obtained the Coroner's Permit to Cremate a Dead Body along with a complete and satisfactory Certificate of Death. 5. The Coroner's Permit to Cremate a Dead Body shall be retained by the crematory and is subject to examination at any time by any coroner or representative of the Kansas Department of Health and Environment. VS 221 rev 11-01 f �