Howk, Katherine x -
l O� OF
PLNE VIEW CEMETERY AND CR
QUAY-ER QUEEN
ER ROAD, EMATORTUM
SBURY, NEW YORK 12804
(518) 745.4476 (518) 745*-4477
Funeral Director
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Of Cremation I I_
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Remarks S�
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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: �! /
Ao►.7��v�.n P� Ini. /�/
(Name) (SOX)
(city)
Vr 0 07o�- (Zip Code)
((Street) ( i Y) (State)
who died on d/ay of ,// /�'i♦ 20.0 T
at__�ti'^.!"�w+'r��C�G.o»�
(Place) V (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) "' (Address)
Relationship to the deceased 6�
Name of Funeral Home �e�e-✓'�'-s"�%�'�i 'V ��'��`/ 0✓�
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or ,as no) cemaker,defibrillator or any other battery operated
device In his or her body. (Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possesslons 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,false or fraudulent.
1�l�/1' � r/Yrro h
(Witness) ( ddress)
3 4 Mkkvi��r !f; Y,
X (Signature and Address of Relative or Legal Representative)
Signed on this date: D` 0
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006
DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name(first, middle, last) 2. Sex 3. Date f De h
W -109
is 1 D d
4. C' /Town of Dea 5. D e of 'rth 6. Place of Birth
�tl�t it a ,
7 Name and Add r of Funeral DirectQyor Auth rized rson
PERMISSION REQUESTED FOR:(Check only one box and compl ppropriate section)
❑Temporary ❑Removal from - Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
(Section B)
SECTION A� (if temporary storage. complete this section.)
Place of Storage(Name of Cemetery or Vault) City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION B: (If removal from temporary storage or disinterment, complete this section.)
Name of Cemetery or Vault from which body is being removed CityfTown Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C� (Complete this section if body will be cremated.)
Name of Crematorium City/Town, State Date
d` r � S' ✓
PERMISSION IS GIVEN TO DISPOSE AID BODY AS STATED AB . (Title 18,V.S.A. 52 1)
Si of CI City wn Date
Signature of Crematorium Official Container Number Yake
SECTION D: (Complete this section if body/cremains will be buried or entombed.)
Name of Cemetery City own Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City own Date
Body/Cremains were ❑Buried ❑ Entombed Date
Name of Cemetery Section Lot Number Grave Number
City/Town, State Signature of Sexton/Cemetery Official
This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18, V.S.A. 5215)