Mulholland, Genevieve L O 74N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '
Name�� i.l V� b' f✓1UL i t Cased ('
Date Of Cremation �rll
Time Cremation Started
Time Cremation Completed
Type of Container 014y) (2,00-1,Zc/ ,
Remarks
��,�
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: 518-745-4476,Crematorium: 518-745-4477
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:
6EA/EVIEUE T Al ux#oa g1VD F�M.9cE
(Name) (Sex)
'�;r, I/y is"7
(Street) (City) --�� (fie) (ZJp Code)
who died on /5 day of ✓t,.yE 20 D
at /Ff✓EN 1VFi9c%N (7/4.CE 1 u i L,*.9 /1 0 VE,QMDN`T
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased o5e O 41
-/Name of Funeral Home � , LZSo4l �—v 1�ye .
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have 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.
(Witness) (Address) / / t�
( M ( 44,1 1/cam d 10 �i7 f// � CS� Ll/l7 i��a �!l N / I D-997
(Signature and Address of Relative or Legal Representative)
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 cremated remains is requested,check here
Revision:July 7,2004
Policies, Rules and Regulations r
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation"signed by the nearest next of kin is necessary 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 Cemetery and 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 are, or are not wholly groundless, false or fraudulent. This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable alternate container. Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three working days(72 hours)of receipt of the
Burial Transmit Permit and Authorization to Cremate Form. The cremated remains will
be mailed via Registered U. S. Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made. There will be a$25.00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $300.00
Children (age 13 months to 12 years) $150.00
Infants (stillborn to 12 months) $100.00
Overtime Cremations (Weekdays) $400.00
Saturday Cremations $400.00
STATE OF VERMONT—AGENCY OF HUMAN%SERVICES—DEPARTMENT OF HEALTH No. 6
OFFICE OF THE CHIEF MEDICAL EXAMINER
4 A.
MEDICAL EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
V[PMON
Full name of decedent �UJ`��� l/
Decedent's address
Date of death Town of death' T/,44,/Z z i
Cause of death certified by r-/r} `1.rJ ,C-LC
Permission to cremate the body of this decedent at v. Lr/ C_-✓��,,��y
(Named address of Crematory)
has been requested by —✓ l/SO y��1A� 2� �1/Ft� �t �� Al V.
(Name and address of Funeral Director representative or person requesting the permit) T '
Vermont Funeral Director License Number:
Being sufficiently informed as to the causes and circumstances of the death of the above
described decedent,permission is her y granted to cremate t body as requested.
v ,�jb9
Dat (Sig 16
ned) G� ,Medical Examiner
Address
Z77 el
18 VSA SEC.5201(b)
DISTRIBUTION:White Original:Crematory via Funeral Home or person requesting permit Yellow:Funeral Home Pink: Local M.E. Goldenrod:OCME
y
MEDICAL EXAMINER'S CREMATION PERMIT:PURPOSE AND PROCEDURE
As outlined in Vermont Statute Title 18,Section 5201,Medical Examiners To reach a Local Medical Examiner to sign a cremation permit:888-552-2952
(Chief,Deputy,Regional,and Assistant)must issue permits for bodies of
persons who die in Vermont and are to be cremated.The OCME will Points to Remember:
maintain a list of Medical Examiners that are authorized to perform this duty A$10.00 fee for reviewing the death certificate and signing the permit is statutorily
for distribution to funeral directors and crematories.The list will be mandated and paid directly to the Medical Examiner by the funeral director or the
distributed a minimum of once per year to funeral directors,crematories and person requesting the permit.
medical examiners,and updated as necessary.Only individuals appearing
on this list are authorized to issue cremation permits. All death certificate amendments resulting from the cremation permit review
process will be issued by the OCME.
The purpose of having a medical examiner review a death certificate prior to
cremation is to ensure that questions about the certification of death are Cremation permits are never to be pre-signed.
addressed before irrevocable disposition of the remains occurs.Following
cremation,there is no way to examine a body.Therefore,the medical Cremation permits are now printed in four-part format.The goldenrod copy is for
examiner must be satisfied that the cause and manner of death are correct the local Medical Examiner to retain.The pink copy is for the funeral director or
and that no further examination or judicial inquiry is warranted before a the person requesting the permit to retain.The yellow copy is mailed to the OCME.
cremation is authorized. The white original is to be filed at the crematory.
The funeral director or other party requesting the cremation permit is If there are any concerns or questions regarding the certification of death,
required to present a copy of the death certificate to the Medical Examiner. cremation will not be authorized until they are resolved.Any questions about
Medical Examiners are required to make personal inquiry into the cause and signing a cremation permit should be directed to the OCME.
manner of death.A review of an accurately completed death certificate may
be all that is necessary. OFFICE OF THE CHIEF MEDICAL EXAMINER
111 Colchester Avenue,Baird 1
If the cause and/or manner of death as it appears on the death certificate are Burlington VT 05401
not accurate or not etiologically specific,the Medical Examiner must initiate Voice:(802)863-7320
an investigation prior to issuing the cremation permit. FAX:(802)863-7265