Allen, James NOUN OF QUEEVBU9�
ra PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral D i r e c t o r i4 �1
Name 2 J .5 � �/Y Case # 4LLZ
Date of Cremation ! c')- ''/ � --/` 3
1
Time Cremation Started �c� ���� ��/►
l
Time Cremation Completed �,',' 100
Type of Container �/4/►_����/I / s / ,
Remarks :
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) $100. 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:
James W. Allen M
(Name) (Sex)
Ordway Lane, North Creek,NY 12853
(Street ) (City) (State) (Zip Code)
who died on 13 day of Dec. 19 93
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Catherine O. Allen, Box 40 , North Creek,NY 12853
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Alexander FH, North River,Ny
IMPORTANT:
I represent that to the best of my knowledge, the deceasedX
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
gr Bless, false or fraudulent.
Warrensburg,NY
(Witness) (Address)
/, �� R O ���,►� SAME
(Signature of Relative or Legal Rep. and Address)
Signed on this date : 12-14-93
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
....
James
W.
_ _ .Allen NI::.:::::_.
Date of Death Age If Veteran of U.S. Armed Forces,
12 13 93 48 War or Dates NA
F- ............................... ... ...
Place of Death Hospital Institution or
City Town or Village Glens Falls Street Address Glens Fa]is Hospital
D,:,:Mannerof Death .::::..:....
...::...
W ® Natural CauseEl Accident Homicide SuicideEi Undetermined 0 Pending
Circumstances Investigation
er e
I f Medical Certifi Nam Title
Q Dr. James Morrissy MD
.................. ........ .:::....:.... ....
Address
Glens Falls,NY
Death Certificate Filed District Number Register�um ,,j
City,Town or Village Glens Falls 5601
Date Cemetery or Crematory
El Burial 12 17-93 Pine View Crematory
....... ........:
®Cremation
Address... .....
.,:::.:::. .. ......::.....::.
Queensbury,NY
Z Date Place Removed
0' E3 Removal and/or Held
H and/or Hold .: _ ........ ... .... .........
rtn;
Address
0..... ...:. .:::.:..:....:..................
QL Date _:.:............... .::.::. Point of::.:.:
cn? Transportation by
p> Common Carrier Shipment
Destination
Disinterment Date Cemetery Address
El El Reinterment
Date....... Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Alexander FH 00017
Address
North River,NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.......--. ......... .........
Address
a>
Permission is hereby granted to dispose of the human /mains escri able as indicated.
r
Date Issued 12-15-93 Registrar of Vital Statistics
( ignature)
District Number 5601 Place City of Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-' f f f
Z Date of Disposition 1,2-i �� Place of Disposition ` /W145-
W
(address)
,w
(section) (lot number) (grave number)
pName of Sexton o Person i Charge of Pre ises ie/ l 141 d 27X 4)
Z (please print)
w' Signature Title ' �' c
DOH-1555 (10/89) p. 1 of 2 VS-61