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Hopkins, Marsha y TOWN OF QUEENSBU"RY Pine View Cemetery and Cremnlorinm 21 Qunker Rond, Queensburi, NY. 72804-5902 (5 18) 74 5-44 76 (518) 745.4477 h11p:11-\v\v.queensbury.net Funeral Director: Name of Deceased: Case Number: �11 Date of Cremation: Retort: T Cq St Time Cremation Started: Time Cremation Completed: 10 a Type of Container: Remarks: M03 %i G /�h - I�tbLjt-� 5 u() /jrj boa., (U: " H0111e of NatitrnI Beauty ... A GOOtt PInce In Ltur " r 1�7 Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury, New York, 12804 Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 ' Audxxtzation to Cremate The undersigned requesffi and aulhortaes Pkte View Crematorium,in as wdence with and subjsd to Its Rules and Regulations to cremate the remains of: Marsha Ann (Crum) Hopkins F (biome) (Sent) 3.9 Fawn Road Gansevoort NY 12831- (SIX") (City) (state) (Wp Code) who died on 21 s t day of April, 2008 at UPMC Presbyterian Hosptial Pittsburgh PA ( ) (Address) Name and eddre ss of naarest living raiefiva or name of pemm aulttoFbft cromeWm Catherine Hopkins 39 Fawn Road (Name) (Address) ReWdonehip to the Daughter Name of Funeral Home Carleton Funeral Home, Inc. IMPORTANT: I represent that to the best of my knowledge,the deaeesed(has)or defrillator,bet",battery pack,power cK nsdlosclNe Implant or radiaectire device in his or her body.(Circle ) 1 cerWy that I#cave tali power and eu wrlIzetlon to anaonge for the cnsnnedw of the rerneft and to direct the disposition of the cremated remains,[bent any perecnel p a i q aesiorts hate ekflar[team removed or may be des hayed,and agree to protect,defend and save harmless Pine View Cremeb3dum from any and all t lairna and demands for ices or damages which maybe made against thsm by resson of or connected with dv oarnwon of acrid renolins as dinxted,whe dw such dab, ar rim ands are or ere not wholly groundless,false or fratbtlertt. / 68 Main Street, Hudson Falls, NY Q - 39 Fawn Road, Gansevoort, NY ( Address of Relative or legal Representative) Signed on this date: Disposition of Oemated Remains I hereby dhect Pine View Crematorium to dispose of the cremeted remains as follows-. Mail to Other arrangemem•Please specify: tf pulvedzstion of erornated remains is requested,dntdt hens XX RevlWwn.April 18,2007 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS NO. U ' Q 2 94 DISPOSITION / TRANSIT PERMIT ;;See reverse side for completion instructions) Section A-Local Registrar or Funeral Director Transcribe information+as listed on Certificate of Death per corresponding item numbers in parenthesis. Full Name of Decedent(1 ) Sex I?,) Date of Death(4 ; Date of Birth( . Marsha Ann Hopkins Female 4-21-08 7-30-54 County of Death (8b.) City,Boro,Twp.of Death (8c.;: Facility Name 8d Allegheny Pittsburgh University of Pittsburgh MedicalCnt . Was Decedent ever in the U.S.Armed Forces? "12.) ❑ Yes El No Cause of Death (2?.} Respiratory Failure Authorized Method of Disposition(Check all that apply) Date of Disposition(=1 ,r ❑ Burial ❑ Entombment © Cremation(Authorization No.,if applicable) ❑ Donation IT Removal from Pennsylvania(Specify method of removal,if applicable ) April 28 , 2008 Place of Disposition(Name of cemetery,crematory or other place as listed in `'em 211c.) Pine View Crematorium Location(City/town,state,zip code as listed in i t-mi 21 d.) County(if in Pennsylvania) Queensbury , NY 12804 SIGNATURES BELOW CERTIFY THAT APPROPRIATE INDIVIDUAL HAS MET ALL REQUIREMENTS OF THE VITAL STATISTICS LAW 35 P.S.,§450.504, 28 PA CODE,CHAPTER 1 AND ANY OTHER COMMONWEALTH LAWS REGARDING DISPOSITION OF DEAD BODIES. Section B—Local Registrar Signature and district number of Local Registrar issuing permit: Was this permit released as a blank pre-signed permit prior to filing the death certificate? ► I/ j Yes ❑ No ----------- - --- -------- Complete Address ; If yes,date released to funeral director: �BQ� /Aw j If no,date permit issued by local registrar: Section C—Funeral Service Licensee`or person acting as such Section D—Cemetery or Crematory Official Funeral Director License# F D 014 7 2 6 L I certify that disposition has been completed by method(s)authorized by this permit in the location as indicated. Signature of Funeral Service Licensee(or person acting as such): Signature of Cemetery or Crematory Official(or representative of facility receiving ated rema' ): _ Date of J -- ------ ---------Q� ---------Date 4—2 3—0 8---- ► ---------------------Disposition 4 ----��--D------ Complete Address Complete Address 300 W. ThirdAve . , Derry , Pa 15627 INSTRUCTIONS FOR DISTRIBUTION This permit is valid for 30 days only from date entered in Section C. Copies 1,2&3: Provided by issuing local registrar to the funeral service licensee(or person acting as such). Distribute as follows: (1) Retained by cemetery,crematory,or facility receiving donated remains after disposition is completed. (2) Submitted by individual responsible for disposition within ten days of disposition to the local registrar in the district where cemetery,crematory, or other facility is located. (if necessary, contact the Division of Vital Records at (800)842-5040, Ext. 656-3154,for the name and address of appropriate local registrar.) (3) Submitted by individual responsible for disposition at the end of each month to: Division of Vital Records, PO Box 1528, New Castle, PA 16103. Copy 4: Retained by issuing local registrar.