Kilburn, Joyce Crawley •
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PINE YIE QUEES'Br(Ific
• W CEMETERY AND CREM QUAKER ROAD, QVEENSEURY ATORTUM
(518) 745-4476 (518)' NEW PORK 1280a
745.-4477
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I :me Cremation Completed 11 ;v;�
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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:
Mrs. Joyce Crawley Kilburn Female
(Name) Pe0
6 Caernarvon Street, Fair Haven,Vermont
(Street) (City) (State) (Zip Code)
who died on 31 s t day of August 2008
at Rutland Regional Medical Center, Rutland, Vermont 05701
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Sally Corey, 2439 Rte 22A North,Fair Haven,VT 05743
(Name) (Address)
Relationship to the deceased DAUGHTER
Name of Funeral Home Durfee Funeral Home, Fair Haven,VT
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive 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 harmless Pine View Crematorium from any and all dawns 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
g...1447,741)mr:28 Caernarvon Street,Fair Haven,VT 05743 (SON)
(Witness) (Address)
'1524( gnature�of Relative or Legal Representative)
September 1, 2008
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 spe ify: Funeral Home will return for Cremated Remains
If pulverization of cremated remains is requested,check here XXXX
Revision:April 18,2007