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Griffin, Gladys TOWN OF QUEENSBURY Pine View Cemetery mid Crematorium 27 Qunker Road, Queenshtiry, NY. ]2804-5902 (518) 745.4476 (518) 745.4477 http //www.queensbury.net Funeral Director: L iayzk'L'L Name of Deceased: s� �� (� r 21 ► �, Case Number: Date of Cremation: - 2 -2-r�© S5- Retort: Time Cremation Started: Time Cremation Completed: / / 0 UA� Type of Container: CL'�. t C fAtZ ���t'I�t�Oi�1 /VL V ai :3 o Remarks: C/V4 " Home of Nnturnl Benuty ... A Cood PInce to Live " i 41 ti0 TOWN OF QUEENSBURY �� y1 PINE VIEW CEMETERY y & CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHORIZATION TO CREMATE 1AG '� ID -j The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of: i Gladys Griffin FPmala (Name) (Sex) Warren St C1PnR Falls NY 1280l - (Street) (City) (State) (Zip Code) who died on 30th day of July ?nnr; at EdCi Park HC Facility (Place) (Address) Name and address of nearest living relative or name of person authorizing cremations: *0 J Daniel S (Tiffin, 8 Traiis End, nueenshury (Name) (Address) Relationship to the deceased san - Name of Funeral Home IMPORTANT:I represent that to the best of my knowledge, the deceased has or , -V7 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;'andnagree. to protect, defend and save harmless Pine View Crematoriuuj�,,from any arrd:ell claims and demands for loss or damages which may be maZIT against them by reason of or connected with the cremation of said remains as directed, whether such claims or demands are not wholly groundless, false or fraudulent. ` itness) (Address) (Signature of Relat' or Legal Rep. and Ad X dress) Signed on this date: NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ` - Burial - Transit Permit Name First Middle Last Sex Evelyn M. Griffin Female Date of Death Age If Veteran of U.S. Armed Forces, 05/19/2005 77 years War or Dates #-r Place 9LQeath Hospital, Institution or or yillaoXXX Glenville Street Address 8 Via Maria, Glenville, N Y 12302 luJ. Undetermined Pending 6 Ma of Death[3Katural Cause �Accident �Homicide �Suicide � � g W Circumstances Investigation Q. Medical Certifier Name Title tJ; Q Patrick F. Timmins 1 I I M. D. Address 895 Riverview Road, Rexford, N Y 1214$ Death Certificate Filed District Number Register Number City, or VillaXXX Glenville g651 83 ®Burial Date Cemetery or Crematory ❑ 05/23/2005 Pineview Crematory tombment Address Cremation Queensbury, N Y Date Place Removed ❑Removal and/or Held and/or Address F_ Hold 0 Date Point of Q Transportation Shipment C3 by Common Destination Carrier F Disinterment Date Cemetery Address . Q�Rinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home JIlson Funeral Home, Inc. 00933 Address 46 Wiiliams St., Wbitehall, N. Y. 12887 Name of Funeral Firm Making Disposition or to Whom l Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human ain described above as indicated. Date Issued 05/20/2005 Registrar of Vital Statistics / s nature) District Number gg51 Place Glenville I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: z ` W Date of Disposition,57-2j-0 !�� Place of Disposition o (address) lU (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises (please print) Signature Title rriv` �O 2 (over) DOH-1555 (02/2004)