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TOWN OF QUEENSBURY
PINE VIEW CEMETERY -
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CREMATORIUM
Quaker Road, Queensbury, New York 12801
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
Dr. Robert C. Schiek Male
(Name) (Sex)
1211 Old Park Ave. Washington, Pa.
(Street) (City) (State) (Zip Code)
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who died on lath day of Sept. 19 88_
at 1211 Old Park Ave. Washington PA
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
_ Arlene R. Schiek 1211 Old Park Ave. Washington PA
(Name) (Address)
Relationship to the deceased wife
Name of funeral home Sullivan Minahan and Potter Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased has or CD pacemaker in his or her body.
(CIRCLE ONE)
I certify that I have the 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 the cremation of said remains as directed, whether such claims or demands are, or are not, wholly
groundless, false or fraudulent.
wife
(Witness) (Signature of Relative or Legal Rep.)
1211 Old Park Ave. Washington PA
(Address) (Address)
Signed on this date Sept. 16, 1988
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangement - please specify:
will pick up
If pulverization of cremated remains is requested, check here X
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday No
Holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone for acceptance
of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of
Queensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authorized person
stating that they do have the power and authority 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 of damages which may be made against them by reason of, or connected
with the cremation of said remains and/or disposition of said remains as directed, whether such claims
or demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to
a regular burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container, Caskets and containers
must be of combustible material.
5. The question relative to cardiac pacemakers must be answered on the authorization to cremate form
before the remains will be accepted.
6. Unless other arrangements are made, the cremated remains will be mailed via Registered. U.S. Mail
within three days of cremation to the funeral home handling the service.
Cremation, Administration Costs and Recording Fee:
Adult $125.00
Children(age 13 months to 12 years) 80.00
Infants(stillborn to 12 months) 45.00
Shipping container, carton and packing fee for shipping and registered priority mail with return receipt
included in the above prices.
ADDITIONAL SERVICE
Storage of cremated remains-per month $ 2.00
Commonvileaith of PennsylvaniaIN # U � Burial or Other Disposition
Division of Vital Records . • #517 of a Dead Human Body
Full Name of Deceased Date of Birth Age Sex to of Deatf►
Dr. Robert C. Schiele 18/24/35 53 male 9 14 1988
Cause of Death Veteran Status Race
(Yes or No)
Ac Coronary White
Place of Death City,Borough,Township County
1211 Old Park Ave. N. Frankliln Twp. Washington
Authorized Disposition(Check appropriate box) Name of Common Carrier
Burial Cremation Humanity Gifts Removal Shipment by Common Carrier
� X�X 0 ® [� U S Air
Disinterment Date of Disposition Name of Cemetery or Crematory County(If in Pa.)
0 Pine View Crematorium
Reinterment 9/17/1988 Address City,Borough,Township
0 Town of Oueensberr N. Y.
I'certify that I have met all the requirements of the Vital Statistics Laws I certify that a death certificate has been filed as required by
and Regul ions. ws of the state. Permission is hereby given to the Person in Charge
`' to transport and/or make final disposal of the remains.
LIT
Signature ofPerson in Charge of Inter t1ri
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925 Allis Ave. Washin to , Pa. J 9/15/1988
Address Sign lure of Registrar Date Issued
Mail To: I certify that the deceased name above was buried or cremated
in the emetery or crematory named.
Division of Vital Records
P. O. Box 1528
New Castle, Pennsylvania 16103 Signature of Cemetery Official Date
Address
See Reverse Side for Regulations
PROCEDURES GOVERNING THE ISSUANCE OF A BURIAL PERMIT
Disbursement of the copies of this permit shall be as follows:
1. To be maintained by the cemetery, crematory, or Humanity Gifts Registry. This copy must contain three signatures to
be valid.
2. To be submitted to New Castle by the individual responsible for disposition at the address indicated on the reverse side
of this form. This copy must be submitted within ten days after disposition. This copy also must contain three signatures
to be valid.
3. To be maintained by the issuing local registrar.
This permit is to be issued only for deaths which occur in Pennsylvania A typewriter, ball point pen,or indelible pencil must
be used in the preparation of this permit. This permit must be presented to the individual responsible for disposition prior to
disposition of the body. The necessary information regarding a disinterment-reinterment permit may be obtained by con-
tacting a Local Registrar or the New Castle office of the Division of Vital Records.
Disinterred Bodies
No dead human body shall be removed from its place of interment unless a disinterment permit is first secured from any local
registrar who is authorized to issue such a permit. The remains of any dead body shall not be exhumed and exposed to view
without an order from a court of competent jurisdiction.