Hulihan, George �o OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Iql�(,�•-, L��
a m e_�EC�12c�- 1-1 V
IAt N Case;
Date OE Cremation 2
le— 2c,
T =me Cremation Started_ �—®
. !me Cremation Completed
oe of Container CV—Qj) '$rA\Z l/ �14` rj S- ��
Remarks 'l
fL ✓ 1� --�
it
i
it
i
i
//pS
TOWN OF QUEENSBURY
PINE VIEW CEMETERY '
8
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:
6E0kof t — 1'r-I IS /1uc,1 NA0 MAL)
(NAME) t t (SEX)
� Biyns Al I/T
(STREET) (CITY) (STATE) (ZIP COD
who died on day of Sri�hn'gh 2003
i
at �IiS 11 niV C-)Z i
(PLACE) (ADDRESS)
Name and address of nearest livingrelative or name of person authorizing cremation:
i
Relationship to deceased
Name of Funeral Home 1tU c, J: Z �'9L
I
i
IMPORTANT
1 represent that to the best of my knowledge, the deceased has or has 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
I
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 laims or n re or are not w oily groundless,false or fraudulent.
( E ) (ADDRESS)
PLC
(SIGNATURE OF RELA IVE OR LEGAL REP.AND ADDRESS)
Signed on this date:
I
I
I
I
i
i
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
Other arrangements - please specify: Z61<-( eiev c;
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,
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 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
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 $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.
$W State of-ermont ,fO
Department of Health �!
Office of the Chief Medical Examiner No.
PERMIT 1*0 CREMATE A DEAD HUMAN BODY -
Full Name of Decedent: �EOg l.�✓rSv r�4 a�
Decedent's Address: 69A-Af xd - yAl/S v7—
Date of Death: Town of Death; et"L (S
Cause of Death Certified by: &r (4 ! 61$&W d,l�+
Permission to cremate the body of this decedent at
{Name and Address or Crematoryr
.nas been requested by 9'c,44ua g Ax ,&,4 kd -� ��'� CJ�rcxe Z4
(Funeral Director Name and Address)
Vermont Funeral Director License Number:
Tieing sufficiently informed as to the causes and circumstances of the death o a ove 'bed
decedent,perm.ssio is granted to cremate t s requested.
Date: q�s1 P.elmM. ca Examiner
AddressOMMOFnMCHWr�sateit<. wt
Iil e�ett—rsn±srB�wv�ennM Rune 1
18 VSA SEC.Sapl(b) WhHr('nnv Fi:neni NMI'� �Nrl a iw+w•'a�,._r.. , utc iv zt