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Schier, Robert C. IT-1 MMA -7 A2 Name r Case.Number Date of Cremation Time Cremation Sfirted Time Cremation Completed— Type of -container h.1Z_f1f IV '-Aemdrks ,446a. �.�M t I (A � ZE Ift 1p qei-,, ,:�a�,J " TOWN OF QUEENSBURY PINE VIEW CEMETERY - b 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) .t 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 A 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.