Gamache, Grace B. zO%N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director )�
Name GR P 1 C0/y1 G�Case #
Date of Cremation
Time Cremation Started 1 (r)
Time Cremation Completed i d, ZO h�^
Type of Container ��,'1 + �r 3 I°�(J GjC Q /—
Remarks :
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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: 6Je�l'
If pulverization of cremate remains is requested, check here-y_ CT
POLICIES, RULES AND REGULATIONS
L. 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) t11,0. 00 Infants ( stlesi lb
to 12 months) $70. 00
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:
Mrs . Grace Bernadette Gamache Female
(Name) (Sex)
85 Main Street Poultney, Vremont 05764
(Street) (City) (State) (Zip Code)
who died on 5th day of March 1996
at Rutland Regional Medical Center, Rutland, Vermont
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mrs. Mary Anne Kendall, 2680 Vt .-RT 30 North,POultney , Vt. 05764
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Roberts-Aubin Funeral Home
IMPORTANT:
I represent 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
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witn ) (A ess)
(Sr ature of Relative o Legal Rep. and Address)
Signed on this date: March 6, 1996
No. ,
r
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent Mrs . Grace Bernadette Gamache
Decedent's address The Elms , 85 Main St. ,Poultney, Vt. 05764
Date of death March 5, 1996 place of death Rutland Regional Medical Center
Cause of death certified by Dr. Victor Pisanelli
Permission to cremate the bodv of this decedent at Pine View Crematorium
Queensbury, New York
(Name and address of Crematory)
has been requested by Jim Aubin of Roberts-Aubin Funeral Home
(Funeral Director)
Vermont F. D.
License No. 1030 17 Allen Avenue ,Poultney, Vt.
(Address of Funeral Director)
Being sufficiently informed as to the causes and circumstances of the death of the above
described decedent, permission is hereby granted to cremate the bo requested.
Date (Signed) r. Mike Scovne
xaminer
Address Green Mt . College,POultn
ey,VT.
18 VSA SEC.5201 (b)