Richardson, Carrie TOWN OF QUEEVBUP.,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ���
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Name ase #
Date of Crematicn/0
Time Cremation Started
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Time Cremation Completed
Type of Container 4-f&V&i9lM fsTG�s�®FT/�/ r Y
Remarks:
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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, 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 ma-y 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. N.- s'-yrafoam 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 $18. 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $155. 00
Children (age 13 months to 12 years) $90. 00 Infants (stillborn
to 12 months) f50. 00
t
TOWN OF QUEENSBURYf
PINE VIEW CEMETERY J vCJ
i
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:
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(I LEI e, i c ha rd-c)nn +* 1 Ie
(Name) (Sex)
� Q p -(D r) t2d f n cl i can Lkc, K)Y I
(Street ) (City) ,r (State) (Zip Code)
who died on ,�3 day of 0(-+e-)her 19
at d i r f-'r)CACI C , Tr, 1 n C)t )o { iDrrh C"-.['��—
(Place) (Add ess)
Name and address of nearest living relative or name of person
authorizing cremation:
Fra n K R i _I�v� r(+-,nn W �3or�h ✓ r, n� VC11C j
(Name) (Address)
Relationship to the deceased �SOY1
Name of Funeral Home BREWER FUNERAI, HOME, INC.
IMPORTANT:
I ;�np
r ent tha to the best of my knowledge, the deceased has or
ha o pacemaker n 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, fal )er fr udlulentV.
(Witness) ( ress)
(Signature of Relative or Legal Rep. and Address)
Signed on this date: ftDk2yy11g
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of D ath Ag If Veteran of U.S. Armed Forces,
p a � War or Dates &,0
Place of Death Hospital, Institution or
City, r Village Street Address . • T �.��
Manner of Death NatLYral Cause Accident ❑Homicide Suicide Undetermined D Pending
Circumstances Investigation
Medical Certifier N e Title
Addr s
Death Certificate Filed District Number Register Number
City o or Village
Date U C metery or Crematory
❑Burial
Address
Cremation
Date Place Removed
8❑Removal and/or Held
and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rer^aina described above as indicated.
I€' Date Issued 9 q Registrar of Vital Statistics �
( ignature
District Number.,
Place / -�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
W. Date of Disposition Place of Disposition �lr/�,���� G�i�M 19
2 (address)
Uj
W
>� ( ection) (I t tuber J (grave number)
GName of Sexton or Perso in Charge of Premises P'B;Q ,� /}'/
g (please print) f
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61