Davis, Dorothy rrO nN OF QUEEN,5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director .Pjaff- 4--"�
Name Z�bg6 Case # s3'?,,3
Date of Cremation ;2Z,3 — QcDc
Time Cremation Started 2�11yl '
Time Cremation Comoleted
Type of Container G�/����� /57►Gi95�4 �/y 09
Remarks :
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_ TOWN OF QUEENSBURY
PINE VIEW CEMETERY -
373
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:
DOS h; Ma r g rlay; g
(NAME) (SEX)
( R (CITY) (STATE) (ZIP CODE)
who died on 17 day of 200_
at
(PLACE) ( ESS)
Name and address of nearest living relative or name of person authorizing cremation: ,
Mrs Dorothy Rediker
Relationship to deceased Daughter
Name of Funeral Home Du r f ee Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in her
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 maybe made .. ,
against them by reason of or connected with the cremation of said remains as directed, whether-
such s or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNXTURE
Sig,
OF RELATIVE O/R LEGA EP. AND ADDRESS)
Signed on this date: / ct< �)
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. - 3130 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.
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 OF VERMONT -
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent Dorothy Davis
Decedent's address 24 Old Etna Road Lebanon NH 03766
Date of death July 17, 2001 Place of death Lebanon Center Genisis Elder Care
Cause of death certified by Dr. Chris Allen
Permission to cremate the body of this decedent at Pine View Crematory
Quaker Road Queensbury Ny
(Name and addrerw of Crematory)
has been requested by Walter Dueharme Durfee Funeral Home
(Funeral Director)
Vermont F. D. V t 1187
License No. P .0 Box 86 Fair Haven, Vt 05743
(Addret,o 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 crer awe a body as requested.
2001 `
Date July 18, (Signed) , ExamiUr' r '-'
Dr . Michael Scovner '
Address
18 VSA SEC.5201 (b) Pou ney, v 4 ;;1f'