Waterman, Jeff ` TO rNN OF 1.1
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PINE VIEW CEMETERY AND CREMATORIUM
WAXER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director —I 157
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Body Delivery Receig
(Required by Section 4145 - NYS Public Health Law
bECEASED PERSON: t
t appears on burial,cremation or transit permit)
9 DATE THAT BODY WAS DELIVERED:
h^. . C. AND REGISTRATION NUMBER OF FUNERAL.DIRECTOR MAKING DELIVERY:
4 e.
(Print Name) (Reg. #)
D. NAME OF FUNERAL FIRM REPRESENTED BY THE FUNERAL DIRECTOR:
(Print Licensed Funeral Firm Name)
E. NAME OF OWNER,OPERATOR,MANAGER OR PERSON IN CHARGE OF
PLACE OF FINAL DISPOSITION WHO RECEIVED THE BODY:
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(Print Name)
CHECK (✓) IF NO ONE IN CHARGE
F. NAME/LOCATION OF PLACE OF FINAL DISPOSITION:
(Name) - (City,State)
(SIGNATURE of Funeral Director) (SIGNATURE o Person Receiving Body)
White Copy-Funeral Director Yellow Copy-Place of Final Disposition Blue Copy-Decedent's Family
DISPOSITION OF CREMATED REMAINS ,
1 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. 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 Costs 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.
(NAME) (SEX)
�L�z�j�f-Gr sTj2�Pr /yff/ 7-/'2.411-c /1/,/. e,97
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20 ,05
at
(PLACE) (ADDRESS) ^
Name and address of nearest living relative or name of person authorizing cremation:
givshA144,1 4,�4'7&—h,4// IV-��J'j-7
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Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or 0�10acemaker 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 or connected with the cremation of said remains as directed, whether
such claims or demands are.or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
4=�-
(SIGNATUYRE OF RELATIVE OR LE AL REP. AND ADDRESS)
Signed on this date:
DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH c �I
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name(first, middle, last) 2. Sex 3. Date of Death
• 4.Cityrrown of Death 5. Date of Birth 6. Place of Birth
7. Name and Address of Funeral Di ector or Authorized Person
ovltinPle14c 1,Ao 6vi1/r'14► 1s 40 `T17t0-tC Al.• /�d'�7
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from KCremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
(Section B)
SECTION •• •rage. complete this section
Place of Storage(Name of Cemetery or Vault) City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION B: (If removal from temporary storage or disinterment, complete this section.)
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTIO ompiete this section if body will be
N e of Cremato " m City(rown, State Da
�hPu�:°w C.y1Ph-I�-7Ga���cc Tcvh oF Qu�'�rs6uK �/ � o�
PERMISSION IS GIV DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
S' re of Clerk r Deputy Citylrown Date
tu
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ureVf Crem wm Official Containe Number Date
r14 l
•N D: (Complete this section if body cremains wW be buried or •
Name of Cemetery City/Town Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A.5201)
• Signature of Clerk or Deputy City/Town Date
Body/Cremains were ❑Buried ❑Entombed Date
Name of Cemetery Section Lot Number Grave Number
City/Town, State Signature of Sexton/Cemetery Official
This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18, V.S.A.5215)