Harney, William TOWN Off" QUEEVBU-q�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director Ra R�
Name &/t(1 l AM yA dAR NIE Case # �
Date of Cremation
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Time Cremation Started "� ® I�-� P � ^^
Time Cremation Completed } 1 , ' .� P 1
Type of Container G �--- C�S� y274 L
Remarks:
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No.
STATE,OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent
Decedent's address 1 ��►^sta�-�� �'- �`Q �''�" � �'�'��
Date of death � n ` Place of death
Cause of death certified by S�-��
Permission to cremate the body of this decedent at
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(Name nand address of emalor_�)
has been requested by `' � ( rl ele 40 —
(Funeral Dir or)
Vermont F. D.
License No.
(Address of Funeral Director)
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 ted.
Date , '� t'J (Signed) < �rEalhirrer
Address C C.C. J c S-7
18 VSA SEC.5201 (b)
JZ)C`--N
TOWN OF QUEENSHURY ~�
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:
Mr. William Harney Male _
(Name) (Sex)
1 RanGnn T.;;ntn Fair Haven Vermont 05743
(Street ) (City) (State) ( Zip Code)
who died on 19th day of January 1999
at Rutland Regional Medical Center, Rutland, Vt.
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mrs. Carol Harney 1 Benson Lane, Fair Haven, Vt. 05743
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Durfee Funeral Hom
IMPORTANT:
I r resent that to the best of my knowledge, the deceased has or
has no pace
maker_)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.
(Wit ess (Address)
404, -& 2zzla�'
(Signature of Relat or Legal Rep. and Address)
Signed on this date: January 20, 1999
A
4
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, bhedk herejC
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 w,ll be
charged the additional $50 .00 .