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Roberts, Howell T09 Y N OF QUEEN4.5BUPy PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSHURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director oy eg Name ` � rrC U), t `�J ��-Lase ## 39 / Date of Crematicn J q Time Cremation Started 10 Al'k Time Cremation Completed - Type of Container OA ?--t3 / tJfi C'v� e ©r Remarks : AV I N 90/riVR-i? 014 2 O , ,- r v 1 11 C, va'/''I No. 3 � � STATE OF VERMONT EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY Full name of decedent Noweii 7homaa Ro&e ztz Decedent's address Date of death Au qu,3 t 11, 19 9 9 Place of death Cause of death certified by D z. C-izemann Permission to cremate the body of this decedent at Pine View C2emat oity Cluakea Road, New yolk 12084 (Nome and addre►ji of Crematory) has been requested by _ lameh C. Aug-in (Funeral Director) Vermont F. D.License No. 1030 266 Aiign Ave. , /you itney, V7 05764 (Addresu of Funeral Direelor) Being sufficiently informed as to the cuuses and circumstances of the deuth of the above described decedent, permission is hereby granted to cremate the body as requested. Date d u rytt G i 1� '^^^ (Signed) n , Examiner —� T d%./II.Ge� Address / U 18 VSA SEC 5201 (L) o- 1 Y�/ .s 7 7 TOWN OF QUEENSHURY pINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 774-44776or if no answer Cemetery 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: N't. Howeii 7homa,3 Rogezta Nape (Name) (Sex) (Street ) (City) tate) (Zip Code) who died on 11th day of Augurt 1999 77 at (Place) (Address) Nave and address of nearest living relative or name of person authorizing cremation: , (Name) (Address) Relationship to the deceased iv-.'ee Name of Funeral Home Roge2tb-Augin Tunezai Home IMPORTANT: I re refit t to the best of my knowledge, the deceased has or has ne 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 Rep. and Address) Signed on this date: i� A"'P DISPOSITION 'OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify: C_A_31« n, c 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.