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Haldenby, Frederick a rl'o q+N OF QUEEN5BURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director SM�� Name C Case # a266 Date of Cremation Time Cremation Started Q Time Cremation Completed Type of Container /Q�lC1�/�� Remarks : 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: (NAME) V (SEX) (STREET) (CITY) (STATE) (ZIP CODE) who died on � day of 200f at A&a (PLACE) (ADDRESS) Name and address of`nearest living relative or name of person authorizing cremation: g�� ds 7�l3 Relationship to deceased Name of Funeral Home ---���-� �✓ r / '/ ' ' 417— IMPORTANT I represent that to the best of my knowledge, the deceased 1 par has n 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. (WITNESS) (ADDRESS) (SI NATU F RELATIVE OR LEGAL REP. AND ADDRESS) Signed 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: -CC�ZC /(� If pulverization of cremated remains is requested, check herex 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. Pre-arrangements 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 $25.00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to 12 years) $150.00 Infants (stillborn to 12 months) $100.00 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. DH-PHS-13TP-89et 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 Fr Harold Hal d n Male May 11 2001 4.City/Town of Death 5. Date of Birth 6. Place of Birth Benson, Vermont July 12, 1930 Benson, Vermont 7. Name and Address of Funeral Director or Authorized Person Fair Haven, James C. Aubin Durfee Funeral Home, 119 No. Main St ,Vermont PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section) ❑Temporary ❑Removal from XXXCremation ❑Burial or Storage Temp.Storage or (Section C) Entombment (Section A) Disinterment (Section D) (Section B) SECTIO orary storage co on.) Place of Storage(Name of Cemetery or Vault) City/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/Town Date Signature of Sexton/Cemetery Official _7Date SECTION3 removal •m temporary storage • • • - section Name of Cemetery or Vault from which body is being removed737n Date Name of Cemetery where body is being taken City/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/Town Date Signature of Sexton/Cemetery Official Date SECTION • • body mll • cremated I - Name of Crematorium City/Town, State Date Pine View Crematorium Queensbury, New York May 11 , 200 PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A.5201) nature o Jerk or Deputy City wn Date f Signat a of Cremat ium O ici ontainer Number ate SECTION D: (Complete this section if body,'cremains will be buried or entombed Name of Cemetery Citylrown 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 ❑Buried ❑Entombed Date Name of Cemetery Section Lot Number Grave Number City/Town, State Signature of Sexton/Cemetery Official This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18, V.S.A.5215)