Benway, Raymond 70q4N OF QUEENSB219�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1-I'Li' 561f
Name 0 9FAI)dVCase # d- �6
Date of Crematicn O / / 2TL
Time Cremation Started /Orr /cz 04 f
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Time Cremation Comp//l��ete�dd //, f, , - ! A r
Type of Container
Remarks :
Ayl N le 11 I's-&
TOWN OF GUEENSBURY
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:
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(Name) (Sex)
/1�91 .L AA //2S `f ,�il°AyJCIb*7 V7_ D r733
(Street ) (City) (State) (Zip Code)
who died on l2 day of 1_j_U411L_ 19
at -f-,6-/C 6EX 1-hP i 7;kL
(Place) Address)
Name and address of nearest living relative or name of person
authorizing cremation:
f�o,�,w-Ae T &0nk)A� R I? 2 An x I/2 5� �f .BRfI t�r,�o h VT 65733
(Name) (Address)
Relationship to the deceased A� 6 _/745e
Name of Funeral Home �/ Soh /-u!?ER/�L �M� ��G
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 cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) (Address)
ignature of Relative r Legal Rep. and Address)
Signed on this date : w �S. 9g
v
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, 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.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent R4,wv
Wq �5t,�
Decedent's address R2 1 We)( Q
1 a& j) ' ( /a
Date of death A-211V Place of death'
Cause of death certified by N 601L AuDo-eiz
Permission to cremate the bodv of this decedent at e1A;'01t' z^GL-4 0
�Q (Name and I I ess of Crcmatom
has been requested by u�-�7 f' )�— t TZ
(Funeral Director)
Vermont F. D. // wt `/-tr
License No. �� L) , "'� ' " f
(Address of Funeral Director)
Being sufficiently informed as to the causes and Kcircustances of the de the above
described decedent, permission is hereby grante the requested.
Date (Signed) ?ec os M.P , Examiner
IZ
Address lAa e- �G(A
18 VSA SEC.5201 (b)