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Ladd, Brian . rrnWN OF QUEEN ,5BU��Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 11 11 Name 13MRfA � q S « Case # Date of Cremation -L'40Ts Time Cremation Started 3 O �1 /�• Time Cremation Completed t �� 1�n Type of Container CA9- -goiq,iP—� CoN-V— 1 CwS6= 6F Remarks : l �J� 5 F G A,�. D M � k 5 Iq /*V\ No. i' u STATE QF VERMONT EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY Full name of decedent Decedent's address L-37-3 -�-��,�, `� Date of death 1--2-.C-Y— Place of death Cause of death certified by ��� Permission to cremate the body of this decedent at ZI-4 y S/�c (Name and address of(:remalon) has been requested by (Funeral Director) Vermont F. D. '/ License No. It 3 � /l��/�•lAewG 5 T, (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 ie body as requested. T� Date © � ���� (Signed) Address �• 18 VSA SEC.5201 (b) C-�\� �¢sT 000 i TOWN OFIWEENSBURY 4ali PINE VIEW CEMETERY & CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 (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: A&e�o, Z4�� (NAME) (SEX) (STREET) (CITY) (STATE) (ZIP CODE) who died on 31tel day of �10520�(� at LAC (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: ow Relationship to deceased Gf/� Name of Funeral Home Jr IMPORTANT I represent that to the best of my knowledge, the deceased has o has no acemaker 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/• 1� 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 cremated 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 or 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 Styrofoam or plastic containers will be accepted. 5. The question relative to cardiac pacemakers must be answered on the authorization to c 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$225.00 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. DH7PHS-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 Brian Edward ladd Mal Ogtober 3,2000 4.C"dyi/Town of Death 5.Date of Birth 6.Place of Birth Bethel June 30, . 1964 Proctor, Vermont 7.Name and Address of Funeral Director or Authorized Person Durfee Funeral Home 119 N. Main St. Fair Haven Verm nt 05743 PERMISSION REQUESTED•FOR:(Check only one box and complete appropriate section) ❑Temporary O Removal from ®Cremation 0 Burial or Storage -Temp.Storage or (Section C) Entombment (Section A) Disinterment (Section D) (Section B Place of Storage(Name of Cemetery or Vault) 7 City/Town,State Date PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. die 18,V.S.A.5201 Signature of Clerk or Deputy. Cltyfrown Date Signature of Sexton/Cemetery:Official Date Name of Cemetery or Vault frdm which body Is being removed City/Town Date Name.of Cemetery where body is being taken Cltf/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/rown Date Signature of Sexton/Cemetery Official Date Name of Crematorium city/Town.State Date Pine View crematorium 7 Quegnabury. - -- P ISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. Title 18,V.S.A.5201 i n re of Clerk uty CltylTown Date �- Bethel 10-4-00 u Si nature of Cremator um Official t1.1 Container Number pate I i Name of.Cemetery• City/Town Date 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 Body/Cremains were p Buried D Entombed Date Name of Cemetery Section Lot Number Grave Number City/rown,State Signature of Sexton/Cemetery Official position.(Title 18,V.S.A.5215) This permit is to be filed with the City/Town Clerk by the loth day of the month following dis