Barnes, Grace TOWN OF QUEENSBURY `
PINE VIEW CEMETERY&CREMATORIUM
1�.
Quaker Road, Queensbury, New York, 12804
Phone(518)Crematorium 7454477 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)
�-/ '�2*�z 7
(Street) (City) (Stat (zip)
who died on / day of
at
(Place) (Addre s)
Name a add t relative or name of person Authorizing cremation:
(Name) (Address)
elationship to the deceasedyL
Name of Funeral Home -
IMPORTANT:
I represent that to the best of my knowledge,the deceased has or has no pacemak 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
wholly groundless, fats or fraudulent.
�fD 711/4'
(Wit s) (Address)
ignature o tive or Legal Rep. and Address))
r/igned on this date: / Q
NEW YORK STATE DEPARTMENT OF HEALTH �7 /Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Grace Barnes ; Female
Date of Death Age If Veteran of U.S.Armed Forces,
�. November 18, 2005 87 War or Dates Arty
Z Place of Death Hospital, Institution or
W City, Town,or Village Fort Ann Street Address 161 Lake Nebo RD
Q Manner of Death FX] Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
(� Medical Certifier Name Title
W Dr. Joseph C. Mihindu, M.D. Dr.
Address
20 Murray St. , Glens Falls, NY 12801
Death Certificate Filed District Number Register N mber
City, Town or Village Fort Ann
❑Burial Date Cemetery or drematory
November 21, 2005 Pine View Crematorium
❑Entombment Address
Cremation Quaker Rd. Queensbury, NY 12804-
z Date Place Removed
❑Removal --7and/or Held
- and/or Address
Hold
Date Point of
0 ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
h ❑ Disinterment
LI ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home2--
Address
407 Bay Road, Queensbury, New York 12804
~ Name of Funeral Firm Making Disposition or to Whom
ix Remains are Shipped, If Other than Above
W Address
a
Permission is hereby granted to dispose of the human
/remains described a e s indicated.
Date Issued Q egistrar of Vital Statistics
(signature)
District Number 111T Place Fort Ann,New York /2-ff2-7
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 11/21/2005 Place of Disposition Pine View Crematorium
(address)
W
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises GA C v4 N
W ( lease print)
Signature Title G /u A''o I�
(over)
DOH-1555 (02/2004)