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Clark, Mary TowN of QUEEVBUqZy PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director �/9w qc'L— Y Name Case # , F Date of Cremation Time Cremation Started4/ h/121 Time Cremation Completed It )X7, I Type of Container II&Dw'�u Remarks : 4eO'9 > TOWN OF OUEENSBURY PINE VIEW CEMETERY 4 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: Mary S. Clark Tamale (Name) (Sex) 24 Madison Street Glens Falls New York 12801 (Street ) (City) (State) (Zip Code) who died on 28th day of January 19 93 at Sarasota Florida (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: Alice Stiles 24 Madison Street, Glens Falls, N. Y. 12801 (Name) (Address) Relationship to the deceased mother Name of Funeral Home Regan and Denny Funeral Home 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, whether such claims or demands are or are not wholly groundless, false or fraudulent. (Witness) y� (Address) (Signature of Relative or Legal Rep. and Address) Signed on this date: February 2, 1993 DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to 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. 411 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 $20. 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $175. 00 Children (age 13 months to 12 years) $ 100. 00 Infants ( stillborn to 12 months) $60. 00 State of Florida,Department of Health and Rehabilitative Services,Vital Statistics APPLICATION FOR BURIAL — TRANSIT PERMIT A. (Type or Print) 1. Name of First Middle Last DATE Month Da Year Deceased OF JAN. 28, 193 MARY CLARK DEATH 2. Place of Death City,Town or Location Name of (If neither, give street address) County Hosp. or MANATEE SARASOTA Inst. 342 MON OWERY AVENUE 3. Name of Medical g I Medical Examiner Address Phone Number Certifier 1950 ARLINGION ST., SUITE 103 JAMES C. WILSON M.D. M.E. Physician SARASOTA FLORIDA 34239 813 51-4270 4. Name of Funeral Home/ Address Fla.Lic.No./Reg.No. Phone Number(Area Code) !! t 204 SEVENTH ST. WEST PAIMEITO FUNERAL HCW PAT1E7.T0, FLORIDA 34221 1563 813 722-7704 5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate Box b ❑ was contacted on within 72 hours after death. He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,and that will complete and sign the medical certification of cause of death. c ® DAVE AT THE MANATEE CO,M.E. OFFICE was contacted on .T N. .9,1993He/she verified that JAWS C. WI SON, M.D., M.E. Medical Examiner,will complete and sign the medical certification. 6. Place of In state cemetery/ Removal Final Disposition: crematory-name/county: g from state Donation 7. Funeral Director/ Signature F.E.No./Reg.No. Date Signed WiserIL 4 1781 JAN. 30 1993 B. BURIAL — TRANSIT PERMIT 1370-C-019 Permit No. Permission is hereby granted to dispose of this body. © A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship would result from filing within the normal time limit.If the certificate cannot be filed within this extended time limit,a"Funeral Director/Direct Disposer Report" will be filed with the Local Registrar of the County in which death occurred. ❑ No extension of time for filing the death certificate reques Registrar or ate Date Certificate Subregistrar Signature Issued: Jan.30,1993 Due: Feb. 11,1993 C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA Signature Medical Examiner Date or Medical Examiner, gave authorization by telephone to Funeral Director/Direct Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting'period of 48 hours after death is required for all cremations. D. CEMETERY OR CREMATORY -�/ .� Methods of Disposition: Place of Disposition / A � 41) � � ❑ BURIAL ❑STORAGE Date of Disposition CREMATION ❑ THER (Specify) Signature of Sexton ) or Person-in-Charge) This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned within 10 days to the local HRS County Public Health Unit in the County where disposition occurred. HRS Form 326,Feb 89(Replaces Oct 87 edition which may be used) (Stock Number:5740-000-0326-2)