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Hurlbut, Raymond C. TOWN OF QUEEVBWZY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director To"t-, / `e(?-." Name LJC c' 14U9, l ease # Date of Cremation 3 Time Cremation Started 'h F-t /V) Time Cremation Completed f� © � OO 1b, y (/ Type of Container Remarks : Z TOWN OF QUEENSBURY PINE VIEW CEMETERY a 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: RAYMOND CHARLES HURLBUT male (Name) (Sex) 7 Washington St Fair Haven Vermont 05743 (Street ) (City) (State) (Zip Code) who died on 8th day of March 19__q_&_ at Residence 7 Washington St . , Fair Haven Vtp= n+ (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: Carol Hurlbut 7 Washington St . , Fair Haven VPrmnn+05ti!43_ (Name) (Address) Wife Relationship to the deceased Name of Funeral Home Durfee Funeral Home IMPORTANT: I rRi2resent that to the best of my knowledge, the deceased has or as 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 to ected, whether such claims or demands are or are not wholly uAdess fa; se, or fraudulent. 119 No. Main St.tness) (Address) Ashington St. , Fair Haven, VT 05743 (Signature of Relative or Legal Rep. and Address) Signed on this date : March 8, 1996 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, chec her e 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 $185. 00 Children (age 13 months to 12 years) $11,0. 00 Infants ( stillborn to 12 months) t70. 00 No. STATE OF VERMONT EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY Full name of decedent Raymond Charles Hurlbut Decedent's address 7 Washington St . , Fair Haven, Vermont 05743 Date of death March 8, 1996PIuce of deatl, Residence, Fair Haven, VT . Cause of death certified by Robert Cross , M.D. Permission to cremate the body of this decedent at Pine View Crematorium Queensbury, New York (Nucor and addresiw of(:rrmutorr) leas been requested by Douglas V. King, Durfee Funeral Home (Funeral Direelor). Vermont F. D. License No. #16 119 No. Main St. , Fair Haven, Vermont (Address of Funeral Direelor) Being sufficiently informed us to the cuuses and circumstances of lie deuth of the above describ d decedent, permission is hereby granted to cremate tl dy us requested. Dale (Signed) , Examiner Address r C� 18 VSA SEC 5201 (b) No. S•rATE OF VERMONT EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY Full name of decedent Raymond Charles Hurlbut Decedent's address 7 Washington SL . : Fair Haven: Vermont. 01-.)7-,13 Datcofdcath March 8, 1996PIaceofdeut), Residence, Fair Haven, VI' . Cause of death certified by Robert Cross, M.L. Permission to cremate the body of this decedent at Pine View Crematorium Queensbury, New York (Nume and YddrPRM of(.renaulory) has been regciested by .Douglas V. King, Durfee Funeral Home Vermont F. D. LiealseNo. #15 119 No. Main St . , Fair Haver., Vermont. (Addrv•s.,of Funeral Dirrrlor) Being sufficiently informed as to the causes and circumstances of the deuth of the above described decedent, permission is hereby granted to cremate t! ody as requested. Date (Signed) i , Examiner Address tp ('tti 18 VSA SEC 5201 (L) ;,. ' J