Williams, Roscoe rrO` +N OF QUEEN4,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
t
Funeral Director 4A4
Name S.D5Q0,4:-' ! l tL .S Case # � 13
Date of Cremation / ��� — aoalct
Time Cremation Started 4i 46' /M r
Time Cremation Completed qr ,56 iqttvz 1
Type of Container of,1 Wj-- �
Remarks :
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TOWN OF QUEENSBURY
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:
P,oscoc CJ 1��'A�s A,4G Lr
(NAME) (SEX)
4'I'L4 A52��'
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of J v , 20 O o
at Q (o K�F 'Flo
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
I�— QSS ; II Ya S r/:..,-F /oct 2Jds-eed— Ki��o;�vh My 1bSs'�l
Relationship to deceased S o'J
Name of Funeral Home fy) e,L Fvry fa A4- fica &-
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as 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.
ITNE S) (AD S)
/(S'GNPrURE OF RELATIVE OR LEGAL REP. AND ADDR SS)
Sig
i ed 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:
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
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.
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roscoe L. Williams Male
Date of Death Age If Veteran of U.S. Armed Forces,
Jul 13 2000 90 War or Dates
Place of Death Hospital, Institution or
City, Town, or Village Fort Edward Street Address296 County Rt. 46
Manner of Death x❑ Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
MD Gerald F. Abess MD
Address
3 Irongate Center, Glens Falls, NY 12801
Death Certificate Filed District Number RegisteruTb
Cit , Town or Village Fort Edward — �7
Date Cemetery or Crematory
❑ Burial July 17 2000 Pine View Cremator
Address
❑X Cremation Quaker Road
oueensbury, NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 101235
Address
82 Broadway, Fort Edward, NY 12828
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 remains described above as indicated.
Date Issued 117 a J000 Registrar of Vital Statistics ,f l D' o �
(signature)
District Number S Place Fort Edward,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition Ptt�f,[��- lCE-
/��
(address)
(section) (lot number) ) (grave number)
Name of Sexto or Pers in Charge of Premises )rVJA O ��l
(please print) t
Signature Title G d J� r