Principe, John Jr. OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Mb " \ �
Name .Lt/}��� L (�� 1Q(, 1��_^C1 — Case # 7�
Date of Cremation l-�� ( �
Time Cremation Started 1 . q 0 n /11
Time Cremation Completed O
Type of Container G J V-naea 4-1'IN
Remarks :
TOWN OF QUEENrSBURY f
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:
John Principe Nale -
(NAME) (SEX)
L L
246 Birch Road Hubbardton Vermont 05732
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 13 day of 11ovember 2004
at His Residence 246 Birch Road Hubbardton, VT 05732
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
David Principe
Relationship to deceased son
Name of Funeral Home Ducharme Funeral Home Inc.
IMPORTANT
I represent that to the best of my knowledge,the deceased has or has no pacemaker 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
matorium 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)
r
j4GNATIJRE OF E TIVE OR LEGAL REP.AND ADDRESS)
' -
igned on this date: a`'
i
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.
No.
STATE OF VERMONT
Y
EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent John J Principe Jr.
Decedent's address 246 Birch Road Hubbardton, Vt 05732
Date of death Now 7 3, 200A Place of death Resi.dencg 2410 Rixch Roa d Vt
Cause of death certified by Dr. Allan 3.ise«ann
Permission to cremate the body of this decedent at Pine View CreJnatoru
_C217gJtier Rnar1 C27-1 sbnr7 TJPE,7 Ynrk 17ROA
(Name and address of Cremator%)
has been requested by —Wa7f'ar Mnn!2arMe
(Funeral Direetor)
Vermont F. D.
License No. 1187 P.O. Box �!74 Castleton, Vt 05735
(Address of Funeral Director)
Being sufficiently informed as to the causes and circums nce, of he death of the above
described decedent, permission is hereby grant o c� to t b as requested.
xt
Date (Sign e Address E„ x�tgine��G�
18 VSA SEC.5201 (b)
DH-PHS-BTP-89a VERMONT DEPARTIVkgNT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name(first, middle,last) 2. Sex 3. Date of Death
John Joseph Principe Jr. Male I November 13,2004
4. CitylTown of Death 5. Date of Birth 6. Place of Birth
Hubbardton I January 10 1943 Mt.Kisco 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
Place of Storage(Name of Cemetery or Vault) 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
SECTIO -
Name of Cemetery or Vault from which body is being removed CitylTown 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 Cityfrawn Date
Signature of Sexton/Cemetery Official Date
SECTION
Name of Crematorium City(Town, State Date
Pine View Crematory Queensbury,NY 11/15/2004
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201)
Signature f Clerk or Deputy, - Cityffown Date
Si atu&of ematorium Official Container Number Date
tz v 14- Ll t 11-17 0
SECTIOND
Name of Cemetery Citylrown 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)