Erikson, Glen r
TO'-N/N OF QUEE9�5BUr
PINE VIEW CEMETERY AND CREMATORIUM \J
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4.477
Funeral Director
Cj
T Svtq Case# �L� l
=a : e Of Cremation
- 1%L- - ►3 - z vo
Cremation Started 11 -3 c>
�M
' ' TE Cremation Completed /4
o e 01 Container gU,•I
Tarks
ra ��
P.) I
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: 518-745-4476, Crematorium: 518-745-4477
Authorization to Cremate
The undersigned requests and authortzes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Glen Erikson Male
(Name) (Sex)
Wells Vt 05774
76 T.ak S End T
(Street) (City) (State) (Zip Code)
who died on 9 day of December 2(94
at Rutland Regional Medical Center 160 Allen Street Rutland Vt 05701
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Claire Schoffstall
(Name) (Address)
Relationship to the deceased NQI r-Q _
Name of Funeral Home D11e1Qa-rme _F!tyAexal—Home Tnc
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
certify that I have 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.
(w' ess) (Address)
A- I S" _
(Signature and Address d6lfelative or Legal Representative)
Signed on this date:
es
Y Q
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
Revision:July 7,2004
A
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Cremation" signed by the nearest next of kin is necessary 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 Cemetery and 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 are, or are not wholly groundless, false or fraudulent. This authorization in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable alternate container. Caskets and containers
must be of a combustible material. No styrofoam or plastic containers will be accepted.
4. Cardiac pacemakers, defibrillators or other battery operated devices must be removed
before any remains will be accepted.
5. Cremations will be completed within three working days (72 hours) of receipt of the
Burial Transmit Permit and Authorization to Cremate Form. The cremated remains will
be mailed via Registered U. S. Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made. There will be a $25.00 charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $300.00
Children (age 13 months to 12 years) $150.00
Infants (stillborn to 12 months) $100.00
Overtime Cremations (Weekdays) $400.00
Saturday Cremations $400.00
• 3� 1
No.
•
STATE OF VERMONT
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent Glen Erikson
Decedent's address 16 Lakes End CT Wells, Vt 05774
Date of death p-=---a. 9004 Place of death Rutland Regional I:edical Center
Cause of death certified by Peter. Stickney
Permission to cremate the bodv of this decedent at Pine Veiw Crematorium
21 Quaker RD Queensbury, W 12804
(Name and address of Crematory)
has been requested by Wa 7 to r n ur•na rme Ducharree Funeral Hone Inc.
(Funeral Director)
Vermont F. D.
License No. 1187 a n Box 474 Castleton_, Vt 05735
(Addres.of Funeral Director)
Being sufficiently informed as to the causes and circumstances of the death of the above
described decedent, permission is hereby granted to cremate
� the bd e
Ed.
DateUc)('( (Signed) aminer
Address
18 VSA SEC.5201 (b)
sz1 )
DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, DisintertrIent and Reinterment
1
1. Decedent's Name(first, middle, last) 2. Sex 3. Date of Death
Glen S. Erikson Male December 9,2004
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Rutland I September 20 1917 Brookl n NY
7. Name and Address of Funeral Director or Authorized Person
Ducharme Funeral Home Inc, 1939 Main Street Castleton,Vt.,05735
PERMISSION REQUESTED FOR: (Check only one box and complete appropriate section)
❑ Temporary ❑ Removal from ® Cremation ❑ Burial or
Storage Temp.Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
(Section B)
SECTION A (if terrporp_ry Sto,��aC complete this se--tic,-1
Place of Storage(Name of Cemetery or Vault) CityfTown,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
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
Name of Crematorium City/Town,State Date
Pine View Crematory Queensbury,NY 12804 12/13/2004
PERMISSION IS GIV ISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201)
Signature of Cle or putt'
�c C own Wte
c� G Q
Si nature of Crematorium Off a Co tainer Number Date
Name of Cemetery City/fown 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)