Brown, Norma 9"'WN OF QUEEN, BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director. �y Eff
Name UO Z ZI r ► 1 , 1ROWN Case # Ir
Date of Cremation (' — 1 D , —`evC) O
Time Cremation Started A ,/lid
Time Cremation Completed
Type of Container GlaNz �
Remarks : 1A 5 b
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TOWN OF QUEENSBURY 2
PINE VIEW QEMETERY
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 t'
to its Rules and Regulations to cremate the remains of:
�� 3t
�i9�� yv4
(NAME)
(STREE ) i
,CITY) (STATE) (ZIP CODE) i
who died on_ day of
at l/-GGr �L / urt!` �,
(PLACE) (ADDRESS) '
Name dad ress41
q near t living relative r name of person authorizing cremation:`�:; r+�t#�� 7�
+o
C J '1
�6Y ra 6183
Relationship to deceased �L �'} 1c) s s}
Name of Funeral Home r�1i iIA .�
ed Iliw
IMPORTANT e, rloi ,3-lup 30T .d
I represent that to the best of my knowledge, the deceased has or has no 0ecemaker iriiw;13P6UP`3
body. (CIRCLE ONE)
rlU .8
_
certify that I have the full power and authorization to arrange for the crematiian'if'ftie°reirf8 Ap
to direct the disposition of the cremated remains, that any personal posses'Gris &Wf T
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:n)dy be,n) r1e73
against them by reason of or connected with the cremation of said remains:as directLd.,, fvh ghWi..-i7
2—MS
ma
rids are or are not wholly groundless, false or fraudulent, 2;rihrni
(WITNE (ADD SS)
( IGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signe on this date: (/axe4eC.- 6�';?0Of1
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
P.M. Monday-
1.
The crematorium will be open for cremations 5s can be made for Sa rday.OPrearrangements
Friday. No Holidays or Sundays, arrangement
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-
i ned by the nearest next of kin or other authorized
3. An authorization for cremation propertysower and authority to arrange for the cremation of the
person stating that they do have the pns, that anypersonal possessions
remains and to direct the dispositionbe destroyed and agree to protect defend and save
have either been removed or may claims ny and son oaorlconnecteddwit nthedcremationoof sad damages
harmless Pine View Crematorium from a
which may be made against them by reasonsu
remains and/or disposition of said remain s as directed,
authorization in addition to a regularare,
or are not wholly groundless, false or fraudulent.
burial permit must accompany the remains.
iner. Caskets
nd
4. All remains must be encased in a casket�or al.sNoable Styrofoamtor plastic containers wal be
containers must be of combustible mat
accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
istered
6. Unless other arrangements are made
cremation to the funeral home handling the service. There U.S. Mail within three days of cre There will
be a$20.00 charge for this service.
Cremation, Administration Costs and Recording Fee:
a 75 Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants(stillborn to 12 months)$
* Additional$5 e0o Saturdays will bei�harged the additona$50.00 ns done after 3: 0 P.M. ay through Friday.
Cremations don
No.
STATE OF VERMON')'
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
f
Full name of decedent Mrs. Norma Mary Brown
Decedent's address Park View Apartment 6, Fair Haven. Vt .
Date of death Oct - 89000 Place ofdeath Address Above (Her Residence)
Cause of death certified by Dt Stephen Rosmus
Permission to cremate the body of this decedent at P i ne V i ew Cr ema t o r i um
Quaker Road, Queensbury. New York
(Name and address-of Cremators)
has been requested by 1 i m Au b i n o f : Roberts-Au b i n Funeral Home
(Funeral Dlrr"or)
Vermont F. D.
License No. 1030 266 Allen Avenue, Pou 1 t ney, Vt .
(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 as requested.
Date °f u / (Signed) �! , Examiner
18 VSA SEC.5201 (b)
°4��� �7= f,5,? 6 �!