Loritts, Marion TORN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Name M19 ;<)1V /�/�/ �� Case #
Date of Cremat i cn lr-)— `
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Time Cremation Started /zil 1 it 4 PIYI `
Time Cremation Completed /)/ 3) Z A 1 '
Type of Container 1 f✓e<o19A�p "z/Vy/ a° O A /- , X
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Remarks :
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TOWN OF GUEENSBURY
PINE VIEW CEMETERY
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:
(Na e) ex)
A P 1
(Street ) City) (State (Zip Code)
who died on ! 7-�' day of "G 19
at �y )�W-I
(Place) (Address)'
Name and address of nearest living relative or nave of person
a o izing cr m tion :
its
Name) Address)
Relationship to the deceased <rep
Name of Funeral Home K� �—
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
di d, wh er such claims or demands a or are t wholly
ro ess, f or fraud len
(Witne ) (Address)
( gnature of Relative or gLegal Rep. And Address)
Signed on this date :
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as f lloows :
t `
Mail to bK12 `L �l�v �C/�lk
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 $175. 00
Children (age 13 months to 12 years) $ 100. 00 Infants ( stillborn
to 12 months) $60. 00
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age 11 Veteran of U.S. Armed Forces,
79 War or Dates Ato
P ce of Death f Hospital, Institution or rr n_ �
Cit , Town or Village 44JVT V S Street Address 1 rh t-C�Nte--1
Manner of Death Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
A!
Address
Death Certificate Filed District Num er Register Number
Town or Village �1 /
Date Cemetery Crem tory
❑Burial
Address
Cremation
r
Date Place Removed
8 ❑Removal and/or Held
•• and/or Address
0
Hold
Q Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
C/Name of Funeral Home �t2o & 1� yr(l �v1
Address
i . Utz
Name of Funeral Firm Making Disposition or to Wh,6m
>..: Remains are Shipped, If Other than Above
Address
r
Permission is her by ntgdto dispose of the human main described atioue as indicated.
Date Issued Registrar of Vital Statistics
.. Ofi
X7'-'��-' _
{signature)
District Number Place \
I certify that the remains/of the decedent identified above were disposed
' of in accordance with this permit on:
DW. ate of Disposition _6 ` Place of Disposition �//�ic��// J C�iC�M11Q 76—IF M
2 (address)
W
t/J
! (section) (lot n mb r / (grave number)
GName of Sexto or Perso in Charge of Premises
z (please print) � r
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61