Hubert, James �O O
F QUEEr\�50uTo�-
PWE YI
EW ,CEMETERY AND CREMATORIUM
C1 }CER R0A* D, QUEENSgLMY NEW YORK 12804
(518) 745.4476 (518) 745.-4477
1 Funeral Director�N -
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Dace Of Cremation
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Time Cremation Star v
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Time Cremation Completed '
Type of Container
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Remarks
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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 auVwrines Pine View Crematorium.in accordance with and suGject to tts Rules and Regulatbns to
cremate the remains of
> (SOX)
(street) CLAY) ( e) (zip Code)
who died on
,� day of—.(24z/20jC
Lf. � 1'�at
(Pima) T )
Name andapdreasof nearest living relative or name of person auvwrkkV aemation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: np �.defibr�ator,battery,battery peck.Power
I represent that to the best of my knowledge,the deceased(has)
cell,rsdloective Implant or radioactive device In his or her body.
I ON*that I have full power and ar dvorindOn to artaga for lea cmmatlon of"0 remains and to died the lion of the
c�er med rernakm then arty peraonai possessions have eititar been removed or may be destroyed.and agree to prated.defend and
same haregainstgarn
by m�� SW MWAksge diredeffW�d,Mmlllm susuch da d rdsN wOrkWGrrjg e�not lyy
(slat a
(Address)
nature and Address of Relative or Legal Representative)
Signed on this date: [/ 3 0-0
Disposition of Cremated Remakes
I hereby direct Pine View Crematod me to dispose of the cremated rem"es Mows:
Mad to
other arrangements-Please spedfY:
If puivatzation of cremated remakes is requested.d w*here
Revision:Apro 18,2007
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NEW YORK STATE DEPARTMENT OF HEALTH ---k
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Post Hubert Male
Date of Death Age If Veteran of U.S. Armed Forces,
War or Datesyps
Place of Death Hospital, Institution or
City, To Street Address
X Glans; Falls 9 North Road
Manner o eath �latural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Ad ress
One Iron ate Plaza Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, To
Date Cemetery or Crematory
❑Burial
Address
®Cremation
Date Place Removed
8❑Removal and/or Held
and/or Address
vj Hold
Date Point of
Q`❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
::>: ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01166
Address
Lafayette11 Street ueensbu N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human mains described apbve as indi ted
?< Date Issued 1 o/30i2008 Registrar of Vital Statistics
(sin re)
District Number 5601 Place r-lens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
gjU Date of Disposition Ib 3i o>� Place of Disposition 1'Inc Vet✓ l re"I"Jo�'l"�-
,! (address)
LU
cc (section) (lot number) (grave number)
Name of Sexton or Person in C arge of Premises
/!� (please print)
W Signature ` Title O-1,101,
(over)
DOH-1555 (9/98)