Nichols, Hazel d
rrOWN OF QUEEVBUP,.,Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Date of Cremation
Time Cremation Started
Time Cremation Completed/ '-o2-6
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TOWN OF [iUEENSBURY
PINE VIEW CEMETERY
aG
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 . Hazel Ellen Nichols Female
(Name) (Sex)
28 Prospect Street Fair Haven , Vermont 05743
(Street) (City) (State) (Zip Code)
who died on
6th day of January 19 98
at
Sager ' s Nursing Home , 28 Prospect Street, Fair Haven , Vt .
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mrs . Rachel Nichols P .O . Box 196 , Whitehall , New York
(Name) (Address)
Relationship to the deceased
Daughter-In-Law & POA
Name of Funeral Home Durfee Funeral Home , Inc .
IMPORTANT:
I re resent 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 cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) (Address)
(Signature of Relative or Legal Foep. and Address)
Signed on this date : January 6 , 1998
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail toAl-ee
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 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 $195 . 00
Children (age 13 months to 12 years ) $115 .00 Infants ( stillborn to
12 months) $75 . 00
* Additional $50 .00 charge for cremations done after 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 . 00 .
No.
P. r
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent Hazel Ellen Nichols
Decedent's address 28 Prospect Street , Fair Haven, Vt .
Date of death Jan. 6, 1998 Place of death Sager ' s Nursing Home ,Fair Haven,Vt .
Cause of death certified by Dr . Peter Di errksen
Permission to cremate the body of this decedent at Pine View Crematorium
Quaker Road , Queensbury, New York
(Name and addre�M of Cremalory
has been requested by James Aubin of : Durfee Funeral Home ,Inc.
(Funeral Director)
Vermont F..D. 1030 119 No. Main St . ,Fair Haven, Vt . 05743
Liecnse No.
(Addrep:w of Funeral Direelor)
Being sufficiently informed as to the causes and circumstances of the death of the above
described decedent, permission is hereby granted to cremate the body as requested.
Date Jan. 7, 1998 (Signed) ,Examiner
Address Green Mt . College
ney, ermon
IS VSA SEC 5:01 (L)