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Edmunds, Edmund TOWN OF QUEENSB`L1P..,Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director RCjb f!C S Qb ! n/ Na m e F-.A- 1Y) u 0 d- Cd-m J2 N c.S C as e # /C9� Date of Cremation f/0(1�^%�— / Time Cremation Started l ' 60 I ' Time Cremation Completed I + L/0 Type of Container CiArA— ®a.P`.A— AJ (7P4;�' Remarks : AM/ N at)IrAmil? 0/y G -5 3 Ala&�67-0 E ° '/5 No. STATE OF VERMONT EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY Full name of decedent fl z. Edmund U iii iam Comundz Decedent's address 298 tuznace Staeet, l ouitneu, Veamont 05764 Date of death 1011511999 Place of death N.iz Rzz idence Cause of death certified by Dn• Nichae e Scovne2 Permission to cremate the body of this decedent at Pine View C2emat o2.ium Quake2 Road, Queen.3Puny, New yo zk (Nume and addreoM of Crrwulory) has been requested by __Jamez Aug.in o,e: Rofeat s-Auein Fune2a e Nome (Funrra) Dir••lor) Vermont F. D. License No. 1030 266 Aiien Avenue, Pouitney, Vt. (Address of Fuorral Director) Being sufficiently informed us to the causes and circumstances of the death of the above described decedent, permission is hereby granted to cr ie body at; requested. I Date Or f 15, I R R 9 (Signed) . Examiner Address IS VSA SEC 5201 (L) i I I I TOWN OF OUEENSBURY 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: (Nave) tSex> (Street) (City) (State) (Zip Code) Coll who died on �-- day of at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: 4'7c/j" (Name) (Address) Relationship to the deceased lfllz�'e - Name of Funeral Home �Iu��Gl.G9 e�"Z7 n IMPORTANT: I represent that to the best of my knowledge, the deceased has or hays 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 ersonaldirect the possessionsshavetion of either the cremated remains, that any p 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) 7 (Sig ature f Relative or Legal Rep. and Address) Signed on this date : ©� � xs;/?F/ . r 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 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 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 .