Siket, George zoq+ ■ OF QUEEVBUPY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /a
Name Q/SV�-� /I� Case #i
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Date of Crematicn
Time Cremation Started
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Time Cremation Completed ✓ 6d jgtM ►
Type of Container r„dM�l ff-2 Z 726 ®L ZiT�L Pony
Remarks :
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P ' I NI r
TOWN OF ❑UEENSBURY
PINE VIEW CEMETERY
CREMA'f OR I UM
Quaker Road, Queensbury, New York 12604
Phone (516) Crematorium 745-447'7 or if no answer
Cemetery 745-4476
AUTHO11IZnTION 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 :
PeorQe Siket Male �..
(Name) (Sex )
332 Lamplighter Acres Fort Edward New York 12828
(Street ) (City ) (State ) ( Zip Code )
who died on fifth day of May 1997 _
at _Glens Falls Hospital
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
Marialinp I;ket 332 Lamplighter Acres, Fort Edward, N.Y. 12828
(Name) (Address )
Relationship to the deceased Wife
Nance of Funeral Home Regan & Denny Funeral Service
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
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 cremat.-io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent .
(Witness ) (Address )
. 4z'c
//1/J?y s:flAyin.r�
(Signature of Relative or Legal Rep. and 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, Ouaker Road, Town of Oueensbury.
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 cumbustible
material . No styrafoam or plastic containers will be accepted.
5. The question relative to card4ac 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 sZ0. 00
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult s105. 00
Children (age 13 months to 12 years ) s11,0. 00 Infants ( stillborn
to 12 months ) s10. 00
AUTHORIZATION FOR CREMATION AND DISPOSITION, 031 Rev.10/9
N TI A THIS I A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING=CREMATION.CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE S
I/We, the undersigned, certify, warrant and represent that I/we have the full legal right and authority to authorize the cremation
processing and disposition of the remains of f;anrna Si ket
(hereinafter referred to as the"Deceased'). Name of Deceased
Date of Death Ma t 5 1997 Time of Death 12:03 ❑A.M. ®p.M,
[/We hereby request and authorize Regan & nPnn� F inaral co,.,,;,.o
Name of Fuaerai Home (hereinafter referred to as the "Funeral Home")to take
possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory').
. ame o rem Cory
/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home.
I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are
returned to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition
of the cremated remains of the Deceased as follows:
Is special handling required? ❑ Yes " No Describe
Description of urn or container selected:
Suitable for shipping: ❑ Yes ❑ No
❑ Deliver to
N.aae.ad Aaeraa or cemetery Cemetery
OX Release to family Marial i na Si kpt wi fa
Name Of
❑ Scattering at sea by Funeral Home or Funeral Home's agent,ed Family Member to Receive Cremated Remains
❑ Ship via
To: Name Address
❑ Other
The cremation, processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions:
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant,
rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other non-
combustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received
by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncombustible materials, I/we
authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container. I/We
further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it
deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard when
placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of implanted
mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the
Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to
cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEAS$D DO❑ DO NOT® CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one-
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the
remains 4# tie Deceased prior to cremation, and dispose of as indicated:
oes<riptiffli W&rt+d Device Disismrildam
i]eae,;,lioa of x
D•e1re
It no instruDisposidium
for disposition is given,such items may be disposed of at the discretion of the Funeral Home.
The creme Container Wmg the remains of the Deceased will be placed in the cremation chamber and will be totally and
irreversibl& destroyed-by proioeged exposure to intense heat and direct flame. I/We authorize the Crematory to open the
cremation cumber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and
thorough trnaation.
Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fiNings, jewelry, and other
personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. /We further
authorize tint it any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they
may be separated from the cremated remains of the Deceased and disposed of by the Crematory.
I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,
including, but not limited to, hinges, latches, nails, jewelry and precious metals, and to dispose of such materials.
Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically
pulverized to an unidentifiable consistency prior to placement in an urn or other container.
Unless an urn or container suitable for shipment ois f purchased,the Crematory will place the cremated remains of the Deceased in a
container which is not designed for any typeshipment.
In the event the urn eor container is insufficient to d in a secondary container and returned oche Funeral Homer togethemodate all of the cremated emains r w thhe D the eprimary urn or container-
rnmAlrlS WIII p _ _ -__e__ _r _._..mot_ --A e6o eacP of the Crematorv's best efforts, it is
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
m le
[: Date of Death Age If Veteran of U.S. Armed Forces,
Ma 5 1997 80 War or Dates _ Army
Place of Death City of Glens Falls Hospital, Institution or Glens Falls Hospital
City, Town or Village Street Address
Manner of Death❑Natural Cause ❑Accident [—]Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
David Schwenker MD
Address
90 South Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
[ City, Town or Village City of Glens Falls -j b C? 1 2
Date Cemetery or Crematory
❑Burial May 7, 1997 Pine View Crematory
Address
QCremation Queensbury,, New York
Date Place Removed
Z ❑Removal and/or Held
... and/or Address
0
Hold
Q Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑ Cemetery Address
Reinterment Date
:> Permit Issued to RegHor Number
Name of Funeral Home Regan and Denny Funeral Service, Inc. 58
Address
53 Quaker Road, Queensbury, New York 12804
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 descri ed above ind' ed
Date IssuedS J 7 Registrar of Vital Statistics
(signature)
District Number�;h J Place -�iv�� �e\�C �_ �C
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition. Place of Disposition /V'6-
(address)
LIJ
CC (section) (lot numberr)�)11 (grave number)
GName of Sexto r Person in Charge of Premises �-,t9Z J/1_10P 7 R t�
F 1 (please print) r.�
W. rtFz Title � �S
Signature
DOH-1555 (10/89) p. 1 of 2 VS-61