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Smith, Frederick rlog+N OF Q,21 E 5B PY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY. NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name /I�� `Jr' L��iT� Case # '/` Date of Cremation Time Cremation Start ed .�� i /"' A /M r Time Cremation Completed 16134:5 tM Type of Container 1?L] Remarks : ,14 ,C 1 ll �a�IA TOWN OF OUEENSBURY PINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (516) 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: (Name) (Sex) - t PC 1 6 rL aD l La b r nd a (Street ) (City) (State) (tip Code) who died on _ J9 day of 19 _ (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: 20 6t„► S iuk (x I PL col ALL, J2,D, 0n L(0,4 NY. (Name) (Address) Relationship to the deceased 1h( it Name of Funeral Home ���� IMPORTANT: I represent that to . the best of my knowledge, the deceased has or a 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 Rep. and. Address) Signed on this date : 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 /c 7 If pulverization of cremate remains is requ sted, check here XX 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. 1 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: N.z. F2ed tick Jamez Smith 17aie (Name) (Sex) 28 %aoz/2ect St- , Faia Haven, Veamont 05743 (Street ) (City) (State) (Zip Code) who died an 14th day of Decemge2 19 99 at the Sa en /Vuazinq Home 28 Paozpect S7. , Fain Haven, Vt. 05743 (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: Dianne 7indaii P. O. Box 513, Caztieton, Ve2mont 05735 (Name) (Address) Relationship to the deceased Daughte2 Name of Funeral Home Daa/ee ;rune/Lai Home 119 Noath Main St. , Faia Hav IMPORTANT: to the best of my knowledge, the deceased has or :as no pacemakvr 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: l3Fk 5 � c,C, Z AUTHORIZATION FOR CREMATION AND DISPOSITION i CE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. ATI�I/5 IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORESIQ1NING ned,certo , warrant and represent that I/we have the full le al n�ht and authority to authorize the cremation,processing and premains j 14 L. "t� 1 ,(: `�1`r! 1 1 I C (hereinafter referred to as the"Deceased"). Name of Deceased Date of Death �5'1 1,2 _Time of Death ❑A.M. ❑P.M. I/We hereby request and authorize 1 ti c li + 1)L/V�sw (hereinafter referred to as the"Funeral Home")to Name of Funeral Home take possession of and make arrangements for the cremation of the remains of the Deceased at I�;Y eyc 1 i s e (hereinafter referred to as the"Crematory"). Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and eustod of the Funeral Home. I/we t the services and ions of ed en the remains o Deceased are rned the possession undersl and custody of the Funeral Home.e. I/We hereby authorize Crematory shall zetthhe Funheral Home to as ange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? ❑Yes ®`No Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No ❑ Deliver to Cemetery Name and Address of Cemetery QI Release to family t«fS N"t r 7,14 Name of Designated Family Member to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via U S Re istered Mail* To: Name: Address: ❑ Other Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance+with all governing laws, e rules,regulations and policies of the Crematory and Funeral Home, and the following terms and conditions: 1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncumbustible materials, I/we authorize the remains of the Deceased to be ible cremation container. I/We further authorize the Funeral Home or Crematory to removed prior to cremation and placed in a combust mare disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard when placed in the cremation chamber. The Crematory will not cremate any human remains which contain implanted mechanical or radioactive device. In the event the remains of theDeceased contain such a device, Iny t e Of by authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased Prior to cremation, and dispose of such items at its discretion. VWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOT m CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposition planted Device Disposition If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will he placed in the cremation chamber and will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they may he separated from the cremated remains of the Deceased and disposed of by the Crematory. 5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but not limited to,hinges,latches, nails,jewelry and precious metals,and to dispose of such materials. 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment. 8. In the event the um or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated r 11 1 1 1 - 1 I . 1 . .1 - T~_.___.__� u_W_ 1_,_J.L._--4.L,.L---;rn-•..—--+.;- REGAN &DENNY FUNERAL SERVICE 53 Qw&er Road Queensbury,New York 12804 (518N/ 792-1114 "Customer's DeSi6thation of Intentions" NameofDeceased:— j j­,; Cremation: -C (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: 0 Burial at bQ Return to Family 0 Entombment at 0 Other (specify): i hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of dw form. (Signature) (Printed Name) (Relationship to Deceased) Ll (Telephone Number) IC remated Remains which shall not have been claimed within 120 clays from the date of cremation may he disposed of by this firm by placement in a columbarium." VIZ- Printed Named Funeral Director Signature of'Fune�dZ&rector Date or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: of Disposition) (Location) (Date) Name of Fencm Making Disposition Signature Date #9 WWI :Funeml Home Cow YELLOW F6=4 Cow PEM.Crematory C-PY CUSMMN Rev.4/96 70 q4N OF QUEEVBU.� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director �� U Name Case # Date of Cremation 2 q q Time Cremation Started I © p Time Cremation Completed I % 3s P, � t Type of Container U10cAA,V7- CON 6 Remarks : 1 b 5 p o►\- � � : a. s /,Y% No. STATE OF VERMONT EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY Full name of decedent Ftgd tick aamez Smith Decedent's address 28 P zoapect St. , Fai z Haven, Ve2mont 05743 Date of death l2ecem 'Z 14, 19 Nace of death Sage2'-6 Nuaain-q Kome Cause of death certified by Da. Dgiartey Permission to cremate the body of this decedent at Pine View C2emat o zq Qu ake2 Road, Queenzku2u, N11 12804 (Name and addrerr of(:rrmator�) has been requested by _132-ean Constant o e the Du2,ee Fune zai Rome (Funeral Director) Vermont F. D. License No. 1174 119 Noath Nani St. , Faia haven, Vt. 05743 (Addresw 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 as requested. Date *Decem9e z 15, 1999 (Signed) , Examiner Address 18 VSA SEC.5201 (b) / �--- �Cc{,(�(.r/L� DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH BURIAL-TRANSIT PERMIT Permit No. Permit for Removal, Disinterment and Reinterment 1. Decedent's Name(first, middle, last) 2. Sex 3. Date of Death 7rzed,z.ick �ame,6 Smith t7aee lDecemgelz 14 1999 4. City/Town of Death 5. Date of Birth 6. Place of Birth 7 a bz Haven Maach 12, 1926 ;a i,,z Haverz, Ve2morz.t 7. Name and Address of Funeral Director or Authorized Person 119 No�z.t h Main S.t. aame,3 C. 4uUn oP Du2 ee funeza K ta-.2 Haven, V7. 05743 PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section) ❑Temporary ❑Removal from X agremation ❑Burial or Storage Temp. Storage or (Section C) Entombment (Section A) Disinterment (Section D) (Section B) SECTION A: (If temporary storage. complete this section.) Place of Storage(Name of Cemetery or Vault) Cityfrown, State TDate PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A.5201) Signature of Clerk or Deputy City/Town Date Signature of Sexton/Cemetery Official Date SECTION B: (If removal from temporary storage or disinterment. complete this section.) Name of Cemetery or Vault from which body is being removed CitylTown Date Name of Cemetery where body is being taken City/Town, State Date PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201) Signature of Clerk or Deputy city own Date Signature of Sexton/Cemetery Official —T-Date SECTION C: (Complete this section if body will be cremated.) Name of Crematorium Cityrrown, State Date .tne View C�zemato2y New 02k 12116199 PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201) S nature of Cle or poputy CitylTown Date t4- (Felt;;' - P� fait Haven Ve�zmont az. Is- /7 i nature of Crematorium Official 61 Container Number Date SECTION D: (Complete this section if body/cremains will be buried or entombed.) Name of Cemetery CitylTown Date PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201) Signature of Clerk or Deputy city own Date Body/Cremains were ❑Buried ❑ Entombed Date Name of Cemetery Section Lot Number Grave Number CitylTown, State Signature of Sexton/Cemetery Official This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18,V.S.A. 5215)