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
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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)