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Treadway, Willard TORN OF QUEEVBU9KY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director *-I j( ao* tkF�6—wKI � LV�"G"'1 Name `�J �jj h AI JgY+�DCase # '2�2 Date of Cremation L — 20e) L4 Time Cremation Started Time Cremation Completed Type of Container Remarks : 0 �4� 9-3;.C) i J 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 PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone(518)Crematorium 745-4477(if no answer) Cemetery 74544.76 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: Willard Treadway Male_ (NAME) (SEX) - Moses-Ludington Nursing Home, Wicker St. Ticonderoga, NY 12883 (STREET) (CITY) (STATE) (ZIP CODE) who died on 6 th day of May 20 04 atMoses-Ludington Nursing Home, Wicker St. , Ticonderoga, NY 12883 (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: James F. Treadway, 2586 NYS Rt. 74, *Ticonderoga, New York 12883 Relationship to deceased Brother Name of Funeral Home Wilcox & Regan funeral home IMPORTANT i represent that to the best of my knowledge,the deceased has or has no pacemaker in his or her body. (CIRCLE ONE) 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 :t reagainst 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 ac.Q.x a 77 L1 . (WITNESS) (ADDRESS) (SIGNATURE OF RELATIVE OR LEGA REP.AND ADDRESS) Signed on this date: ✓ , a 05/08/2004 09:45 5185854475 WILCOX REGANry PAGE 01 NEW YORK STATE DEPARTMENT OF HEALTH Bu Vital Records Section rial _ Transit Permit in Name First Middle Last Sex .Veteran Date of Death 8 Veteran oNUS.Armed Fiirces, 83 vrs. No War or Dates 5/6/2004 Place of Death Hospital. Institution or City,Town or Village Town of Ticonderoga!r.Street Address Moses-LUdington Nursing„ Home Manner af Death 12 Natural Cause [] Accident [-]Homicide 0SUicide E] Undetermined E] Pending Circumstances Investigation Medical CarRier Nam Title Richard McKeever M.D. 1 Ok R istrict Number Register Number City,Town or Village Town of TiconderoSa 1 1564 37 Date z Cemetery or Crematory DBurial 5/7/2004 Pine View Crematory ` : Address Wremation ueensburv, New York .......... ..................... Date Place Removed Removal and/or Hold and/or Hold Address ................ Date Point of 0 Transportation byl Shipment .......... Common Carrier ..................... Destination Disinterment Date Cemetery Address ..........1. ............. Date Reinterment Cemetery Address xb Permit Issued;o Registration Number Name ofFuncralFirm Wilcox & Regan funeral home 01933 .................. ............. Address 11 Alcronkin St. . Ticonderoga, New York 128.83 Name of F,_-neral Firm Making Disposition or to Whom Remains are Shipped, N Other than Above Permission Is hereby granted to dispose of the human r"ains described abo as Indicated. 1 N Date Issued 5/7/2004 Registrar of Vital Statisticsz7pn�c'� 1,12 & signaturep District Number 1 rA4 Place mown nf Ti pond girnaa I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Id 57 Date of Disposition Place of Disposition �v KA& -td 12 I 1_1K (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Promises rz)q xrt (please pdrt) Signature Title DOH-1 555 (10/89) p. 1 of 2 VS-61 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex W ,.l...ar.c ....... Tz.e.a.d.way ...Ma.l.e.............. Date of Death Age If Veteran of U.S.Armed Forces, 5/6/2004 83 yrs. War or Dates No ........................ ......... ................................................... Place of Death Hospital, Institution or City Town or Village Town of Ticonderoga Street Address Moses—Ludington Nursing Home ��� Manner of Death l'7 Natural Cause Accident Homicide Suicide Undetermineds� Pending KXl Circumstance Investigation ..................................................... .....:.............. ... ........ _ ........ ....................... ....::.:................................. .....::::: 4 Medical Certifier Name Title © Richard McKeever M.D. ..............:..:.::.:...:........................:::.:..: Address 102 Race.._.Track Road,,,..T conderoga�.:::N..ew York 1.2.88.3.... ........ Death Certificate Filed District Number Register Number City,Town or Village Town of Ticonderoga 1 564 37 Date Cemetery or Crematory ❑Burial 5/7/2004 Pine View Crematory remation Address .::. ::...::.:... QueensburY..:::..New York .......... ................................................................_ . Z Date Place Removed 2 [] Removal and/or Held t4 and/or Hold :.:...........:::.::. ..._..... _ ........: ........ . _. ................. Address Q...........................:...::::......................:::...................................................... ........._ ....:.: . ....... GL Date Point of ) ❑Transportation by Shipment p' Common Carrier Destination ..:...: ...:.....:..:..:......... ❑ Disinterment Date Cemetery Address . :..::....:...............................::....... ... ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Firm Wilcox & Regan funeral home 01 933 ... . .. _ ........ Address 11 Algonkin St. , Ticonderoga, New York 12883 .. ..... . :::::.:. ... :::::.... .: :.-. .... .. .......... f-, Name of Funeral Firm Making Disposition or to Whom g Remains are Shipped, If Other than Above ......... _...... . Address #Sa .................................................................................................................................................................................................................................................................................... Permission Is hereby granted to dispose of the human r ains described abo as indicated. » Date Issued 5/7/2 0 0 4 Registrar of Vital Statistics signature District Number 1564 Place Town of Ti rondProga I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition,`S i i.6'l Place of Disposition /0% r 4 j% U F_ ic) C rt _)CC p, U (address) w 1) (section) (lot number) (grave number) pName of Sexton or Person in Charge of Premises t40— (please print) w Signature ' Title C RF—m A 4-6 iZ DOH-1555 (10/89) p. 1 of 2 VS-61