Clark, Warren E L O 4N OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
- c Funeral Director15/' lu a
Name 1,J A- (ase # l9 LA
Date of Cremation cx 1 3
Time Cremation Started
9
Time Cremation Completede � _ to
Type of Container olggD Oom2z coqv— l J1 CA5e OF'A�
Remarks :
21
1fi. f� CO n
I
I
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (516) 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:
o"( tC E-- 4 �4 " /C--
(Name) (Sex)
(Str et ) (City) (State) (Zip Code)
^`
who died on da� , y of "f 19
at
(Place) (Ad ress)
Name and address of nearest living relative or name of person
authorizing �c�"remmation :
I- y �l
✓10L l"� 6 Lo,_fK 1 0� a L ) o./r� �� �Or ' 1� , N 11�goZ7
(Name) J (Address)
r
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
�fias no pacemak 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.
w-:
(Witness) (Address)
^� Yt
(Signature of Relati a or Legal Rep. a Address)
Signed on this date :
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 ❑ueensbury.
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 $185. 00
Children (age 13 months to 12 years) t11,0. 00 Infants (stillborn
to 12 months) $ 70. 00
NEW YORK STATE DEPARTMENT OF HEALTH * 6
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
—7 _ War or Dates
Place—of Death / Hospital, Institution or
City, own or Village C/�^� �a J15 Street Address
anner of Death®Natural Cause ❑Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name 1 it
c,r�e rz
Address
D th Certificate Filed W trict Number R gister Nu r
it own or Village
Date Cemetery or Crematory
El Burial / C l .cv f
Address
®Cremation `
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
0 Date Point of
N ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home.1�,� O c_ O C a S
Address !� / _e_ / � � Ue G_ ar
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as' dicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number Place 71 Vie, /. /L Aj y.
I certify that the remains of the decedent identified above we�4 disposed of in accordance with this permit on:
w Date of Disposition Place of Disposition �i�le t��J 6Re; -�(� °� ) /��
2 (address)
ku
secti n t n mb rave number
GName of Sexton or Person in Charge of Premises ? k-4 4 (g
z (please print)
Signature Title CR cjvL Sir
DOH-1555 (10/89) p. 1 of 2 VS-61