Beaubriand, Ruth TO'74N of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 64j I.
Name C)-T +� ,9'r'➢U)o f- I A 110 C a s e #
Date of Cremation t 2 ®G
Time Cremation Started /n
Time Cremation Completed s .�
Type of Container oA `�)owz-� ./AA
Remarks : n
e.L4 61'J l��1fPi a ' 1 q&A A
q 47
s��/YJ
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose .)f 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 clays 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 necesuary. -"
2 . Pine View Crematorium is ' located on the grounds of the mine
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 nine 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 nrt wholly
groundless, false or fraudulent. This authorization in adlAition to
a regular burial permit must accompany the remains .
4 . All remains must be encased in a casket or suitable LIternate
container. Caskets and containers must be of combus,.:ible material .
No styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers muss: be answered on
the authorization to cremate form before the remains wili 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 $195 . 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 .
or
TOWN OF OUEENSBURY
PINE VIEW CEMETERY
R
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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) (Sam)
(Street ) (City) (State) ( Zip Code )
who died on -7 `14h day of 4Ck_U [4
at — kLL ci i R Chi ) +o-. /\LY.
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)Relationship to the deceased _ D
Name of Funeral Home W ; l n oX
IMPORTANT:
I r ent that to the best of my knowledge, the deceased has or
as nv 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 removec4 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.
T Cii2.c_c) .
,."?Witnkow
e dares:)
(Signature of Relative or Legal Rep. and Address)
Signed on this dates ,-- I — 014
i
05/08/2004 09:45 5185854475 z G
r WILCOX REGAN PAGE 02
NEWYORK STATE DEPARTMENT OFHEAITH Burial - Transit Permit
Vital Records Sectlon
Name First Middle Last Sex
Beaubriand ... .w.:,:.. ,_.,.:.:..::.. Female,:.
: 6 Date of Death Age H Veteran o1 U.S.Armed Forces,
iH' 5/7/2 0 04 9 0 errs. War or Dates No
Place of Death ; Hospital, Institution or
City,Town or Village Town_ of Ticonderoga: Street Address Moses—Ludington Hospital
INannerYaf Death Natural Cause El Accident M❑V Homicide MV❑ Suicide 0 Undetemiinedx F Pending r l
Circumstances Investigation
�lilxzC4.
Richard McKeever w w M.D.
10,2 Race,Track Road�,w Ticonderoga, New York 12883 MN�
Death Certificate(riled" � District Number x � +M� Register Number N
Town or Village Town of Ticonderoga` 1564 38
Date Cemetery or Crematory
❑Burial 5/7/2004 :...�w .. ,M �. ...�:.v.v..Pine View Crematory
Cremation ..Address`. :..,,.�
Queensbury, New York
......:...........:: .....::
:. Date : Place Removed
O �] Removal i and/or Held
} : and/or Hold Address :..:..:.,..V......... ,.,.,.,. , :. :.. ....,...,.,.,,, :. .,v.... ...:.....h,.,,, v.w .:: ,..,.,.,,.:.,. :.,,,,....,..:w..v.v...:.
,..N .... �. N .........
"DatANM,: .Point of' v,. :.: ., ..:.....:.........., ..:. :..,....:...:.. ....., ...w.....,.....:.. .,.:...... .....
10:OTransportation by Shipment
Common Carrier p ......
'. Destinatpn
:: :..v:.,�._.,..,.,,.,::.:...,w..:....,.:.,....��.�.,....::.v:.,n..w...M,,,,,w::....�...M..:.,...,,.:.....w,....,�.;v.,......,:..:.:.,,..::::...vr,..w.,.:sw.,�,.,,,..:::.:..:.,,.::s:.....,,,,..,,:....:.,,.:..:....:..:..:..�.w.::..::.::.::.,....,.:.::...,.::..,.v.�.:..,...,:...:....,..
Date Cemetery Address
Disinterment
,..vM..:.,...:.:.:.........::._w., .:.Date.....:h...,.,.,, .r..,.:.:..,.....:......,,.K...:.., ,..Cemetery Address'`.,:.,nv:...,:w.:......:.�....,.,.., ,.:,,�.:,:....::...�,.�.w..,,. ....�..,::.:.:..,..:.,,.:
Reinterment
Permit Issued to Registration Number
' Name of Funeral Firm Wilcox & Regan funeral home 19 , ....,........,....
< ,:.;:.:..,,,..:..,.v.:: ::.:.:......, •....v.w ..xh..,v ..,..„.,:..,,._ ..ww,.....n:............,.,....:..v.,..:,.,.:.:�.,.,,...,.,....:........,,:;::.:.:..,....:,,.:...::::..,..:...,.,..,:`.:..... .. :3....:..:.::..... .
�± Address
11 Algonkin St. , Ticonderoga, New York 12883
tL Name of Funeral Firm Malting Disposition or to Whom
Remains are Shipped. K Other than Above: .:.,.,vM::..,:.......:.,k::.., , ....,�..�w .:. .... .......v.,. ,. .,.. s.,.. v.,. ,.v.,. ..,:..:..:.:,.
Address
Permission Is hereby granted to dispose of the human mains describe ove as Indicated.
xR' Date Issued 5/7/2004 Registrar of Vital Statistics
< (si9 )
�s District Number 1 564 Place Town of Ticonderoga
/",',• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'+Z> Date of Disposition Place of Disposition P; Ci k 1%M hr
+ ? (address)
(section) (lot number) (grave number)
-i'
::p Name of Sexton or Person in Charge of Premises
9i (P19ase lamnt)t
Signature Title C, d
bowiss5 (10/89) p, 1 of 2 VS-61
Z �G
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth........::...............:..... . E. Beaubriand Female
Date of Death .. .... ..... ....... .............
.. . ......:...:......:.... .
Age If Veteran of U.S.Armed Forces
5/7/2004 90 yrs. War or Dates No
......... .. : :::.
Place of Death .......
Z Hospital Institution or
City,Town or Village Town of Ticonderoga Street Address Moses—Ludington Hospital
. ...........:.................... .
W Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
.:. ................:::...... . ..................... ..-.......:...:... .. .......::... fCUfi1S
min n
Circumstances investigation
W Medical Certifier Name Title
Richard McKeever M.D.
_:.::::.
Address
102 Race Track Road, Ticonderoga, New York 12883
Death Certificate Filed District Number Register Number
City,Town or Village Town of Ticonderogai 1 564 38
Date Cemetery or Crematory
❑Burial
5/7/2004 Pine View Crematory
..... ..... .
Address _ ....:: ........ ......... .........,..
Cremation
Queensbury, New York
Z Date Place Removed
2 Removal and/or Held
i—< and/or Hold ....................... .. ....... .... ... .::: :::.:. ...... ....
I'N
Address
0......:.:.... ::....I...::......:.:..::..:::...................... .........- ......:. ....::: : ...... . .:. .. :::: .:. .. ::.....
__
AL> Date Point of
cn< Transportation by:: Shipment
p> Common Carrier
Destination
:.........:........:. ........ .... ..... ........ ... ...... ........
..................
Disinterment : Date Cemetery Address
...::::. .........:...:.............;..... ....-..... .. ...... ...... ........
Reinterment Date Cemetery Address
Ej 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
`g Remains are Shipped, If Other than Above
......... ....... .... ... ............ ....
;tr: Address
U:
> '
Permission is hereby granted to dispose of the human. mains descrirove as indicated.
DateIssued 5/7/2004 Registrar of Vital Statistics sr� �"ti
(signal r )
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 67'1 t')LC-°c LA Place of Disposition P,14LU
1;, f/� t✓kJ C fZE�Y'r�CG�2 �11✓`�
2', (address)
WCn'
(section) (lot number) (grave number)
cc
O'
0 Name of Sexton or Person in Charge of Premises GW Yl,`1 C' N—r
Z; (please print)
w; Signature G-6/", Title
DOH-1555 (10/89) p. 1 of 2 VS-61