Chicoine, Richard TO q4/N OF QUEE9 5B`Z.l� y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
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PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY PURSUANT TO NEW YORK STATE PUBLIC
HEALTH LAW SECTION 4145(2)(B)
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
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2. DATE THE BODY WAS DELIVERED
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3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
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4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
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5. NAME OF PERSON IN CHARGE OF CEMETERY
6. ISIGNARI rFUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
DISPOSITION OF CREMATED REMAINS
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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. Prearrangements
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 $20.00 charge for this service.
Cremation, Administration Casts and Recording Fee: Adult$225.00 Children (age 13 months to
12 years) $115.00 Infants (stillborn to 12 months) $75.00
' 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.
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:
Richard Chicoine Male
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 1 8th day of November 20 03
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(PLACE) (ADDRESS)
Name and address of nearest I'ving relative or n me of person au orizing cremati
Relationship to deceased daughter r �/
Name of Funeral Home M.B. Kilmer Funeral HOme
IMPORTANT
I represent that to the best of my knowledge, the deceased has Eno 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 orconnected with the cremation of said remains as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS) `
(SIGNATURE OF RELATIVE O�ir: �, pP. AND ADDRESS)
Signed on this date: