Hoskins, Jeffrey OF
QUEE9�0U(�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4-476 (518) 745.-4477
Funeral Director MR
game
Ca s e# �I�3
Dace 01 Cremati.on �l
vGfo�� Z] 700g
Time Cremation Started S
Time Cremation Completed
Type of Container
Remarks
s Est
0
_ '30 ���
# f1`13
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) (sex)
(Street) (City) (State) (Zip Code)
who died on d5 day of D tt 20 vS
at (Piece) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) U (Address) `
Relationship to the deceased
Name of Funeral Home b + 1
IMPORTANT:
I represent that to the best of my Ivrowledge,the deceased(has) ( no maker,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 possessions have either been removed or may be destroyed,and agree to protect,defend and
save hamdess 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.
(witness) ( )
�/
�` (Signature apU Addeeis of Relative or Legal Representative)
Signed on this date: C�c Z d & __._ --
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
NEW YORK STATE DEPARTMENT OF HEALTH tf 493
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffre J. Hoskins Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 25 2008 55 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village City of Albany Street Address Albany Medical Center
Manner of Death ❑Natural Cause Qx Accident Homicide Suicide R Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
ddr�" '
Death Certificate iled City of Albany District 1 er Register Number
City, Town or Village
Date Cemetery or Crematory
❑Burial October 27, 2008 Pine View Crematory
Address
Cremation Quaker Road Yueensbury, New York
Date Place Removed
0 Removal and/or Held
and/or Address
�"Eli Hold
Q Date Point of
Q Transportation Shipment
10 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to q Broadw y Fort Edwa d New Yorl Registration Number
Name of Funeral Horn M.B. Kilmer Funeral Home 1 1 1 5
Address
82 Broadway Fort Edward, New York
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 r ;i"I"de 'rib ed a ve as indicated.
Date Issued 1 0—2 5—2 0 0 8 Registrar of Vital Statistics
rgnature)
District Number 101 Place Albany Police Dep Lent Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f--
Date of Disposition 10-27^0$ Place of Disposition ?,"v �(u �r�•�
(address)
Ld
rn
Ix (section) ! (lot number) (grave number)
0 Name of Sexton or Person in arge of Premises �`jo� P►lr{(-
(please print)
Signature Title C�c4CGr
(over)
DOH-1555 (9/98)