Rooney, Nancy Town of Queensbury
pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
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) ( ) C�
(fit) (am►)
r '� �� 2007
who died on I.1
at (Address)
(Place)
Name and address of nearest living relative or name of person 80hmbPV aemedw: gf b O 7(Name) t
Relationship to the deceased
Name of Funeral Home
IMPORTANT:I represent that to the bast of my Imowledge,the deceased(has)or(has no)pacemaker,defibtillatix,battery,battery peck,Per
can,radioactive impiard or radioactive device in his or her body.(Circle One)
I Oartify that I have full power and auftrtw iort to arrange for the ae wAlon of the remains and to direct the disposition of the
cremated remains,that arri Personal possessions have either been removed or may be daWayed,and agree to protect delend
tht
save harmless pine View Crematorium front any arid an dalims and demands for loss Or damages which which may be made against
am
by reason of or amnected with the aeration of said reingia as directed,wharf er such delms or demands are or are not wholly
groundless,false or
IL,
tress � tAddness)
BSI )e�bl�� -
(Signature and Relative or Representative}
Signed on this date:yTa::—�
Dlsposkion of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the pemoled remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
NEW YORK STATE DEPARTMENT OF HEALTH x - ** 'D%
Vital Records Section Burial - Transit Permit
Name t fiddle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates 7�
Place_QLZXeath Hospital, Institution or
Ci ow r Village Street Address
Manner of Death 793 Natural Cause ❑Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Nga Title
` O
Add r ss
LDeath ficate Filed istrict Numbe`r� Register tuber
to or Village T
Dat Ce ery or Crematory
El Burial - /.��1
Cremation Address
FDate Place Removed
❑Removal and/or Held
and/or Address
Hold
Q Date Point of
NQ Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registratio Number
Name of Funeral Home /!��
Address
Name of FuneralWaking Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described aboveawindicated.
Date Issued — —D Registrar of Vital Statistics (/
—y— (Sig re)
District Number, �5 Place �/.�i� // t� �l �05
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
UjDate of Disposition 7 16 /01 Place of Disposition Roe Vol r 1,4"
(address)
LU
N
(section) C (lot number) (grave number)
0 Name of Sexton or Person i Charge of Premises �C,P�� lh►v)t-
g (please print)
Signature Title � Gr
(over)
DOH-1555 (9/98)