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Taylor, Richard L O Y VN OF QUEEVBU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name E l e-t'' (2-U Case # Q Date of Cremation, -zoo Time Cremation Started FA Time Cremation Completed Type of Container(f. Wf- rGC)A?D-d -������1 < P�M Remarks : moo© k- C,J ) 2 S )\2-tj TOWN OF QUEENSBU,RY PINE VIEW CEMETER`'- 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) U (STREET) (CITY) (STATE) I PUC ODE) h who died on day of 20LI— ate--� (PLACE) (ADDRESS) �( Name and address of nearest living relative or name of person authorizing cremation: Relationship to deceased Name of Funeral Home �— IMPORTANT I represent that to the best of my knowledge, the deceased has or as no cemaker 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. r� \ '(WITNESS) (ADDRESS) (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: �2 3 �- 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 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 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. yv`1 TOWN OF QUE.ENSBURY 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) V (SEX) PP U (STREET) (CITY) (STATE) !PUC ODE) ` h� who died on day of 20LL at (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: Relationship to deceased o�o� Name of Funeral Home__ r1�• IMPORTANT I represent that to the best of my knowledge, the deceased has orocemaker 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) (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Richard Edwin Taylor Male Date of Death Age If Veteran of U.S.Armed Forces, F September 2, 2004 74 War or Dates 2 Place of Death Hospital, Institution or W City,Town, or Village Argyle Street Address Home Manner of Death ❑ Natural Cause ❑ Accident ❑Homicide ❑Suicide Undetermined Pending W Circumstances Investigation Medical Certifier Name Title W Dr. Brian King, M.D. Dr. Address 3 Irongate Ctr. , Glens Falls, NY 12801 Death Certificate Filed District Number Register u ber City,Town or Village Argyle 5 9�0 ❑ Burial Date Cemetery or Crematory ❑Entombment Address Pine View Crematory Cremation Quaker Road Queensbury, NY 12804 Date Place Removed ❑Removal and/or Held and/or Address Hold - Date Point of ❑Transportation Shipment by Common Destination Carrier Date Cemetery Address [�Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 101150 Address 82 Broadway, Fort Edward, New York 12828 ~ Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above W Address a Permission is hereby granted to dispose of the human re ns described bo as indicated. Date Issued Q ! Registrar of Vital Statistics �.. - (signature) District Number Place Argyle,New York t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition ��� 'd Place of Disposition pine View CrematorV W (address) 0 r lot lilt- j//�' G l� �� rf f Gk I (sectiony� 12 t number (grave number) Q Name of Sexton o{Person in Charge of Premises (y,:,•-- ' 61 bL} �� ,J1__ W /'7 Es print) 1 Signature �i . Title (over) DOH-1555 (02/2004)