Hagenlocher, William rro RN OF QUEEMB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEEINSBURY, :r`EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name k /V�r�—/f se # pc. Vg
Date of Cremation '
Time Cremation Started (1 �
Time Cremation Completed t4 V PT
Type of Container' n�.�AWL2 c"C (0-T7
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:
(NAME) (SEX)
/ p /Ua�Z; i /�o d GAT/�1 c� c/� G,S ��--
(STREET) (CITY) (STATE) (ZIP CODE)
who died on of y day of 20_0_�
at 3 ) 9 �1-b►2 ,��ct J
(PLACE) (ADDRESS)
Name and address of nearest livingrelative or name of person authorizing cremation:
�l • /W-Q4A//Ocku
Relationship to deceased Ule�ce
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased 4s o as no acemaker 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 r connected with the cremation of said remains as directed, whether
such clai s r ema s re are n holly groundless, false or fraudulent.
(W ) ADDRES
OF LA R P. AND ADDRESS)
Signed on this te:�
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. 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.
No.
STATE OVVERWAT a
EXAMINER'S PERMIT TO CREMATE�A DEAD HUMAN BODY
Full name of decedent 1 T13
Decedent's address 3 1 :) ,in f t h ''_o a d, �'a s t l e c n n , t/t _ , 05735 b O
Date of death.:is y 24, 210012 Place of death 110 r t'1 .a s t 1 e t O n
Cause of death certified by !O 61 n Co h l o n
Permission to cremate the body of this decedent at Pine View %"'r--.;3 t O r y
aua!:er .Lead :Oueens'bury, �,,;Y
(Name and address of(:rematory)
has been requested by `Ll t e r 11ich a r1ne
(Funeral Director)
Vermont F. D.
License No. VT 1 l Al ILL)- E;nx 191 Pou l t uay ,Vt O5764
(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 rem to 0e"l odv as requested.
Date (Signed) \�-' L �`"�'^�' , Examiner
Address ,7 . �•�r}x3
18 VSA SEC.5201 (h) +i')
No.
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent
Decedent's address 319 North Road Castletan , Vt . , 05735
Date of deathMa y 24, 2001 Place of death 319 North Road Cast 1 e t o n
Cause of death certified by John Conlon , AD.
Permission to cremate the bodv of this decedent at P i ne View Crematory
Quaker Road Oueensbury , NY
(Name and address of Crematory)
has been requested by Wal t P r Thu r ha rme
(Funeral Director)
Vermont F. D.
License No. VT 1187 P_n_ Box 181 Poul tney ,Vt05764
(Address of Funeral Director)
Being sufficiently informed as to the causes and circumstances of the death of the above
described (decedent, permission is hereby grante to em to a dy as requested.
IrLDate S I � ��� (Signed) �k� , Examiner
' Address
18 VSA SEC.5201 (b)