Cooper, Fred G. jotul,b v Qtea SLtry.
rIPJE VIEW CEMCTERY and CREMATORIUM
QLtAKFR ROAD. QUEENCQURY, NEW YORK 12801
(518) 798 4 72G
(518) 793-9777
Funeral Dirictor
tivne e — Case No. J �
Dale aE Cremation -71111
,ring Cremation Started
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,1,irue Creak3Lion Completed
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No.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decendent aOn6ikv--
Decedent's address G�L N1
Date of death / V Place of death �U. eg ej,
Cause of death certified by
Permission to cremate the body of this decedent at P, 'o
N
ame an o Crematory)
has been requested by e('" VrlhC.h 11
(Funeral Director) /
Vermont F.
License No.D. � �Du Th 10/74e 1dL./. /g�� � V-� dJ J n
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(Address of Funeral Director)
Being sufficiently informed as to the causes and circumstances of the death of the above described
decedent,permission is hereby granted to cremate the bod equ
Date (Signed) - -- i
Address '�-
1S VSA SEC.5201 (b)
0
DISPOSITION OF CREMATED REMAINS
I heretFy direct Pine View Crematorium to dispose of the cremated remai as follows:
3�� L '
Other arrangement - please specify:
If pulverization of cremated remains is requested, check h
q , ere
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 to 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. No stycafoam or-"plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
R. 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. There
will be a $10.00 charge for this service.
Cremation, Administration Costs and Recording Fee:
Adult $140.00
Children (age 13 months to 12 years) $90.00
Infants (stillborn to 12 months) $50.00
ADDITIONAL SERVICE
Storage of cremated remains - per month $2.00
TOWN OF RUEENSBURY
PINE VIEW CEMETERY
do '
CREMATORIUM
Quaker Road, Rueensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
'fhe undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
Na tn e x
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x UT- 7zl-
(Street) City State Zip Code
who died on Ze A' day of 19 ?A
at Lt
Place Address i
Name and address of nearest living relative or name of person authorizing cremation:
U-E-evl% Pr RLA9r--LW e I I V
Name Address
Relationship to the deceased
Name of the funeral home ��
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has n 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
lAddr
ade a st them by reason of, or connected with the cremation of said remains
d, eth r such claims or demands are, or are not, wholly groundless, false or fraudulent.
e C
Signature of Rel ive o Legal Rep.
s f dress)
Signed on this date
90