Hillis, Dorothy r r
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PWE YTEW QUEE9\�50Urky
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CEMETERY AKD
QVR ROAD, QUEENS8 CREMATORIUM
URY
(518) 745.4476 , NEW YORK 12804
(518) 745'•4477
Funera
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Oa � e Of Cremation Case#.
Time Cremation
Started e7 ,�{�
T ' ^e Cremation Completed hD",
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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 sub)ect to its Rules and Regulations to
Cremate the remains of-.
(Name) a —
S - 4-
(Street) ( ny) (State) (Zip Code)
who died on TM day of 0 20Q�
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased %.._.
Name of Funeral Home M R Ki 1 mar F inPra 1 Home
IMPORTANT:
I represent that to the hest of my krwwledge,the deceased(has)Ot
pacemaker,defibrillator,battery,battery peck,power
cell,radioactive implant or radioactive device in his or her body.(Circle )
I certify that I have full power and aufhortzation 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 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 wholy
groundless,false or fraudulent.
�� (w� (Address)
l
X Signature and Address of Relative or Legal Representative)
Signed on this date: d c-* L — v
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 pulverisation of cremated remains is requested,check here
Revision:April 18,2007
NEW YORK STATE DEPARTMENT OF HEALTH i - V
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dorothy Hillis Female
Date of Death Age If Veteran of U.S.Armed Forces,
F October 6, 2008 92 War or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Daniel C. Larson M.D. Dr.
Address
453 Dixon Road, Glen Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 1 "Oil
❑Burial Date Cemetery or Crematory
October 7, 2008 Pine View Crematory
❑Entombment Address
Q Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
4 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 101114
Address
136 Main Street, South Glens Falls, New York 12803
~ Name of Funeral Firm Making Disposition or to Whom
IX Remains are Ship ed, If Other than Above
W Address
a
Permission is hereby granted to dispose of the hu em ' escribe ovt as md_' ated.
f
Date Issued Registrar of Vital St istics
(signature)
District Number
'` Place Fort Edward,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
WDate of Disposition 10/07/2008 Place of Disposition Pine View Crematory
W (address)
�J
(section)
(lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises
2 (please print)
Signature Title
(over)
DOH-1555 (02/2004)