Chizmar, Thomas J. f
50tun v ueenj ttry.
rlrtE VIEW MVICTERY nd CREMATORIUM
QLIAKF.R ROAD, QUEENSQURY, NEW YORK 12801
(518) 798 4 72G
(518) 793-9777
Funeral Dirictor Al)O/PF,,�,�
tJ•�mA /si #ONl/gS G' t�Z/Ylsl�/lr Case No. 1/D
Dale of Cremation AQ ou —qoZ
I
Tints Cremation Started 7 �Q ��/� r
f
Time Cremtion Cumpleted e ��� �Q , �►/)
'I}qxj of Container C/91 D96/9
1
f?cnw�r.ks _,0411421� , ��s- a D
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify : We will return for Cremains
If pulverization of cremate remains is requested, check here 00=
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
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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:
Thomas J. Chizmar Male
(Name) (Sex)
Hubbardton, Vermont 05749
(Street ) (City) (State) (Zip Code)
who died on 24th d a y of October 1992
at Rutland Regional Medical Center, Allen St. , Rutland, Vt.
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Mr. Frank Chizmar 3 Cottage Street, Fair Haven, Vt. 05743
(Name) (Address)
Relationship to the deceased Brother
Name of Funeral Home Durfee Funeral Home, 119 No. Main St. , Fair Haven, Vt.
IMPORTANT:
re resent 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, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
/ (Witness) (Address)
v (Signature of elative or Legal Rep. and Address)
Signed on this d a October 25, 1992