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Callahan, William r• 7otVl'b U uee` i lief y. riNE VIEW CEMETERY , nd CREMATORIUM Uu QUAKER ROAD, QUEENSQUI?Y, NEW YORK 12801 (518) 798 4 726 (5I8) 793-9777 Funeral Dirictor �/ tl�me e ► &itk k J' , d2 /7 zyk Case No. At UaLe ot: Cremation x� "/Z- lq� '1'inr Cremation Started Ig I, /"/ Al Time Cremation Completed �,�� 1, 441 of Container C-19 90 d 5 t�cnw�r.ks AV A4/d dd/&UEf O* ' -i i ziz f r© _/ _ iyo Loel- p6i'm 3 TOWN OF QUEENSBURY PINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to crema a the remains of: (Name) �- (Sex) ZZ^ L���-r�✓?,�t//�'f' aJ/ ��?'�ro�n/� a�►��/,j�F�S /1> ;' %Zc�6C�- (Street ) // (City) (State) (Zip Code) yh who died on j day of \�i11� 19 f2— at C 11 AAA /92 (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : '(Name) (Address) Relationship to the deceased Name of Funeral Home Z LL/If/_SD%1-) /- a��°E� � ,�� IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no 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, tether such claims or demands are or are not wholly grog 4 e r f udulent. i 4k si (Address) (Signature of Relative or Legal p. and Address) Signed on this date : �-rL_ Ai DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : --- —I l /� Mail to N/.S�/G' T Other arrangements - please specify : If pulverization of cremate remains is requested, check here 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. No styrafoam 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. 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. There will be a $10. 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $155. 00 Children (age 13 months to 12 years) $90. 00 Infants (stillborn to 12 months) $50. 00 ' f T0114N OF" QUEEVBU-QZY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral DirectorCJ��� Name 4 21,4 4 1,I7/M Case #��Y: Dat a of Cremat i on A-2-�3� _ /c-'c- Time Cremation Started � ; 3 pi/h r Time Cremation Completed/CEO Type of Container .-,^'le Remarks : 1019 11 llcvlM 02 i J Pr M 1 I I C;L f�7 �n�► r j DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify : 9UCf'tb".�f akff WX' ^k- t - If pulverization of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 1. The crematorium will be otae-n 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. N, s+ yrafoam 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. 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. There will be a $11F. 00 charge for this service. Cremation, Administration Costs and Recording Fee : Adult $155. 00 Children (age 13 months to 12 years) $90. 00 Infants (stillborn to 12 months) $50. 00 R t � TOWN OF QUEENSHURY PINE VIEW CEMETERY a CREMATORIUM ` Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 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: Cell l a' Ir) �-T OdHahaiq Jr. a le- (Name) (Sex) .4145firsj 6t n (Street ) n (City) //��(��State) (Zip Code) who died on 1J�'[r(',/')') b r day of 1)(remba— 19 c at /P lia/ Y�!�l�/�/�4Y�� (Place (Address) Name and address of nearest living relative or name of person authorizing cremation : alel-sm 6r1nr)6 lld-hm ' / vto J(Name) (Address) Relationship to the deceased Name of Funeral Home l�i�m ,�urke %Sons IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (Circle One) I certify that I have the full power and authorization to arrange for the cremi.; ion 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. , (Witness) -� (Address) (Signature of Relative or Legal Rep. and Address) fined on this date: 2,— NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First „ Middle , La � Sex � � Date of Death Age If Veteran of U.S. Armed Forces /� 3(} `�d2 S7 War or Dates /9ss /9� 7 9 .. ......... .... . PI a of Death �A � Hospital, Institution or City Town or Village (,I.0 -z` Street Address �j� � : .....annerofDeath ::.:.:.. U etermined. ..:.:. Pendiri.:::...... W: Natural Cause Accident ❑ Homicide Suicide g Circumstances Investigation ....:. : :.. .:..: ...... ... ......_ W Medical Certifier Name Title o Ham..................................:. .:. .. H Death Certificate Filed Di rict Number Register Number Cit Town or Village 2 6 G' Date Cemetery or Crematory ❑Burial /c? 3/ 9.2 .................. _ ... _. ;Cremation Addre s :.::........ ......- - Z Date Place Removed 2 ❑ Removal and/or Held F and/or Hold :Addrr-ess.... . ............... :.. N .................... . ..... .... ...:::::: ......... ...: . c3. Date Point of cn, ]Transportation by Shipment pl Common Carrier .......:......::.. .:::............................. ........ ....... Destination .... ..: ....... ........ _ ...... .. ❑ Disinterment Date Cemetery Address .................................. ry . ❑ Reinterment Date Cemetery Address Permit Issued to nn LL pp Registration Number Name of Funeral Firm �v/e&t'l � -C1J �1 Address .................. .....:. ... ::. . Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above OC ................. :.......:.....:..........:..:..::W: Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued / - /—9,L Registrar of Vital Statistics (signature) District Number Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition fez��/-90/- Place of Disposition �jr/y�1/li� GJ /(�/H���/U/� W (address) W' cn (section) (lot number) (grave number) cc _ r , ����� l�� 4J p Name of Sexton or erson in Charg a of Premises Z (please print) p ,/ W Signature Title WX DOH-1555 (10/89) p. 1 of 2 VS-61