Hoenck, Hans TO WY� OF lam. E
PUYE VIEW CEMETERY AND CREMATORIUM �y
Q11'AXER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Dace Of Cremation
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Time Cremation Started ► ., Cj J7
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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of-
IN►�5 �o��ICK M
(Name) (Sex)
�5(0 i co601) Cc c7sb �Y �a
(Street) ' (City) `��r,/ L(,S�ta�tte (Zip Code)
who died Ion 2� day of 't)6 ewbct " 20
at O� lV!h�PI -/H—
(�) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
�7 c�l�y F�DEAJCK
(Name) 11 (Address)
Relationship to the deceased /yl PT--
Name of Funeral Home�eQCl fiL and-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) no) maker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(CirclUINK
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 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 cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless or�7Z
Mr ) ( )
aC
Tignature and Address of Relative or Legal Representative)-
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: -Th rU-1JEkA L 60X-9-
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
- V S 40
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hans Hoenck Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 21,2008 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
iz Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
to Circumstances Investigation
Medical Certifier Name Titl
Address
Gam. `J
Death Certificate Filed District umber Register Num er
City, Town or Village Glens Falls,NY 5601 �
❑Burial Date Cemetery or Crematory
November 2 2008 Pine View Crematorium
El Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& DennyFuneral Home 01482
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I~:+ Remains are Shipped, If Other than Above
M Address
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Permission is he eby ranted to dispose of the human ains described above as indi ated
Date Issued Registrar of Vital Statistics ��
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were dis osed of in accordance with this permit on:
Z `LU Date of Disposition i� Place of Disposition �� 1ftL-j Ci.-civrive%'
2 (address)
W
N
IX (section) q/ lot number) (grave number)
QName of Sexton or Person in Ch rge of Premises !N1 5 S�h�li
Z
Signature (please print)
W
/ Title C��I"iATOR
(over)
DOH-1555(02/2004)