Duross, Helen TOWN OF QUEE9�5BUPJ,"
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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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 C=RGEOF EMETERY
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
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7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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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,
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.
TOWN OF QUEENSBURY Sys
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(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:
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(NAME) t I (SEX)
M(aCt�A - k v A li c)is _ .T i �'r�: (�i✓YCX�Ct l� 7. 1 c��'c�
(STREET) (CITY) <3 (STATE) (ZIP CODED '
who died on cQlf ` K day of b)P-T"
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(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
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Relationship to deceased
Name of Funeral Home f (Yl
IMPORTANT
I represent that to the best of my knowledge, the deceased has o as no pa maker in his or her
body. (CIRCLE ONE)
I certify that 1 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
rematorium 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.
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SS) (ADDRE )
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(SIGNATURE OF WEGATIVE OR LEGAL REP.AND ADDRESS)
Sign on this date: la - A G -L,3 —
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section . Burial - Transit Permitsy�
:.::.
Name First Middle Last Sex
Helen Mary DuRoss Female
.......:.:.........:.:....::...........:..:.:.::......:......:.
Date of Death _...:. ......
12/26/2003 85 yrs. If War or Dates eran of U.S.
Armed Forces,
........................ _::....:
s
Place of Death Hospital, Institution or
j City,Town or Village Town of Ticonderoga Street Address Moses—Ludington Nursing Home
...
w Manner of Death M Natural Cause Accident Homicide Suicide Undetermined Pending
.:.:::.. ............
ndetermin n
Circumstances Investigation
Medical Certifier Name Title
!G Glen Chapman M.D
> :................:.............:::.:............:..::...............::..:.........
Address _ .....
P.O. Box 29, Ticonderoga,
.::..............::...:...............::::::.::...............::..:::::..::......:::.:...................: ..... ....New...York 12883
Death Certificate Filed District Number Register Number
City,Town or Village Town of Ticonderoga: 1564 80
Date Cemetery or Crematory
❑Burial
12/30/2003 Pine View Crematory
............:::.::.. ........
Cremation
Address
Queensbury, New York
......I...........................................:: : .......:::... ...... ...... .:: .... ...... _......
Z Date Place Removed
O; Removal and/or Held
H' and/or Hold ........................ ...:..................... ........ ....... - .. ..... .. .......
Address
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o....................... ......:..:...........................:................................ ......... ...... ..... ...
>L1L Date Point of
.u) Transportation by Shipment
p Common Carrier -
Destination
.............................................................. . ....... ... .... ...... ... .......
Disinterment ............ Cemetery Address
................................. ...:..:.::..; ..:. ..... ......... ........ ... ...... ........ .. ........... . .... ......... ...
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Wilcox & Regan Funeral Home 01933
..:.::....:::............................................................................ ................Address
11 Algonkin St. , Ticonderoga, New York 12883
........... ..... . ::.::.......... _ _::.::... :
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, H Other than Above
....::.:......:.:....:::. ...............:...........:...:..::.......:.:......................... _...:..... ..... ................. : .. - .......... ... ................ .......... ...
Address
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Permission is hereby granted to dispose of the hum �rema�iinsdde�scrl d above as indicated.
Date Issued 12/30/2003 Registrar of Vital Statisti
(signature)
District Number 1564 Place Town of Ticonderoga
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition �" r- 2,'OL' Place of Disposition � r�E�J L/ t' to�Z '
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(address)
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N' (section) (lot number) (grave number)
p! Name of Sexton or Person in Charge of Premises yk,l Z
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Z (please print)
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DOH-1555 (10/89) p. 1 of 2 VS-61