Loading...
Higgins, Robert TOWN OF QUEEVBU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director l2LX5/ IeffE Name e2 I 7- /�r�lr _Case # /� ✓� Date of Cremation Time Cremation Started �Z/ g �- /i/1 Time Cremation Completed Type of Container Remarks : 0r�i/1 , '911 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 : 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 $20. 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $175. 00 Children (age 13 months to 12 years) t100. 00 Infants ( stillborn to 12 months) $60. 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: Ie C(Name) (Sex) (Street (City) (State) (Zip Code) who died on 1� day of �c�� rt iy-� 19 �� at INC S. (Plac ) (Ad ress) Name and address of nearest living relative or nave of person authorizing cremation : j (Name) (Address/b Relationship to the deceased , Tc— Name of Funeral Home Vv ome JK� 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 grow dless fat for _fraudulent. ,�'� cue� ���u..o•� (Witness) (Address) ` �.-. . :�1�t�vo,, � ,�e� . 338��Si ature of_ Rn / Leg 1 Rep. a Address) Signed on this date: /I/O►/ ��� IM] 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 Day Year Deceased OF ROBERT JOSEPH HIGGINS DEATH November 16, 1993 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Polk Haines City Inst. Heart of Florida Hospital 3. Name of Medical Medical Examiner Address Phone N r�ber Certifier 2y3-83 i6 Kollangun Chandrasekhar,MD 1XIPhysician 350 First Street N. , Winter Haven, Florida (813) 4. Name of Funeral Home/ Address Fla. Lic. No./Reg.No. Phone Number (Area Code) Direct Disposer Lane—Holt 233 N. Ninth St. Funeral Home Haines City, Florida 1709 (813)422-3371 5. Check a 0 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 ❑ was contacted on . He/she verified that Medical Examiner, will complete and sign the medical certification. 6. Place of In state cemetery/ Removal Final Disposition: matory - name/count from state Donation 7. Funeral Director/ ignature F.E. No./Reg. No. Date Signed 'Dweet-9 F. Mark Sweat :r 2400 November 17,1993 B. BURIAL — TRANSIT PERMIT 1709-243 Permission is hereby granted to dispose of this body. Permit No. KA 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 wit the Local Registrar of the ty in which death occurred. El No extension of time for filing t eath certificate reques Registrar or Date 11-17-93 Date Certificate Subregistrar Signature Issued: Due: 11-21-93 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 � l Methods of Disposition: Place of Disposition ���y//4��c C64E4_ z ❑ BURIAL ❑ STORAGE Date of Disposition 'CREMATION ❑ O HER (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)