Lyons, Russell rro OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '�U C
Name) C:7 tJ Case#
Date Of Cremation 1 rl
Time Cremation Started . 'qo
Time Cremation Completed
Type of Container �.14�"2-J �J CJ✓�� GptA /V1 , �, ��i-- �405 1�}�'1
Remarks
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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, I
arrangements can be made for Saturday. Pre-arrangements by
telephone for acceptance of remains is necessary.* j
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 j
material. No Styrofoam or plastic containers will be accepted.
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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.
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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 $100.00 charge for cremations done after 3:00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $100.00 Any remains received after 3:30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
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TOWN OF QUEENSBURY J, .
PINE VIEW CEMETERY
CREMATORIUM '
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 7454477(if no answer)
Cemetery 745-44.76
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.
Ru szett E. Lyons Mate
(NAME) (SEX)
46 N.Lchots Street Rutta.nd, Vt 05701
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 5 day of Januan y 200 3
at haven Heatth Cane. 46 Nichots Stxeet, Ruttand, Vt 05701
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mu. Maxy Jane Eaton 50 Ca4na4von Street Faig Haven, Vt 05743
Relationship to deceased SiAten
Name of Funeral Home Duchanme Funena Home Inc_
IMPORTANT
I represent that to the best of my knowledge,the deceased k u o as no acemaker in his or her
body. (C!RCLE 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
matorium 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 cl ims or demands are or are not wholly groundless,false or fraudulent°len �1
(WITNESS) (ADDRESS)
(SI AIKURE OF RELATIVE OR LEGAL REP.AND ADDRESS) i
Signed on this date:
w No.
STATE OFI'ERMONT '
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY •�-
Full name of decedent Rws seZt P. l uon s
Decedent's address 46 Nichot,6 Street Rutta.nd, Vt 05701
Date of death Jan. 5,2003 Place of death Haven Heatth Cane
Cause of death certified by Dn. atan Eizman.
Permission to cremate the bodv of this decedent at Pine View Cnematony
4uakeA Road 2ueenzbuxy, NY 12804
(Name and address of Cremator%)
has been requested by watten Duehaxmg Duehanme Funenat Home Inc.
(Funeral Director) I
Vermont F. D.
License No. VT 1187 P.p. Box 474 Caus.t.Petnn, Vt OS735 I
(Address of Funeral Director)
Being sufficiently informed as to the causes and circumstances of the death of the above I
described decedent, permission is hereby granted to cremate the body as requested.
Date �'S`(� (Signed) /% ?l/1/!t C� `, /ll�f/ , Examiner
Address
a76G �6/1zn Rod /�rA�it° wrl psi' VT
18 VSA SEC.5201 (b) dS�S7
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