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Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery. The
crematorium operates Monday through Friday from 7:00am 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
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 authorizes Pine View Crematorium,in accordance with and subjedt to its Rules and Regulations to
cremate the remakes of::
Harriet E. Davis Female
(Name) (Sex)
7 Timmerman Ave. , St. Johnsville, NY 13452
(Street) (may) (State) (Zip Code)
who died on 'j J day of_ 7:TA n/ 20 O 5'
at L-e-Ma 97r..G rq r- s NK
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Catherine L. Dunn, PO Box 275, Newcomb, NY 12852
(Name) (Address)
Relationship to the deceased Sister
Name of Funeral Home Alexander-Baker FH, Warrensburg. NY
IMPORTANT:
1 represent that to the hest of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to daect 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 harmles�.�Crematorium from arty and all daims and dernartds for loss or damages which may be made against them
by rea�'d#or with the cremation of said remains as directed,whether such daims or demands are or are not wholly
groom,false or fraudulent.
�l
(w. ) (Address)n \
l.{i,t L.Q� vi
(Signature and Address of Relative or Legal Representative)
Signed on this date: 0 S
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: FH will pick up
If pulverization of cremated remakes is requested,check here X
Revision:July 7,2004
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle _ Last Sex
Harriet E. Davis Female
Date of Death Age If Veteran of U.S.Armed Forces,
January 30,2005 65 War or Dates
Place of Death Hospital, Institution or
ZCity, Town or Village City of Little Falls Street Address Little Falls Hospital
WQ Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide El Undetermined El Pending
Circumstances Investigation
U Medical Certifier Name Title
W Chris Mosher Herkimer Co.Coroner
Address
42 N. Ann Street, Little Falls, NY 13365
Death Certificate Filed District Number Register Number
City,1WV)W V;R4& Little Falls 2129
❑
Date Cemetery or Crematory Burial 02/01/2005 Pine View Crematory
Cremation Address
Queensbury,NY
Date Place Removed
Z ElRemoval and/or Held
p and/or Address
Hold
55 Date Point of
N ❑ Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
❑
Reinterment Date Cemetery Address
❑
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00034
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
aPermission is hereby granted to dispose of the human r mains descri d abov as indicated.
Date Issued - / - Registrar of Vital Statistics
gnature)
District Number 2129 Place City of Little Falls, nY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z 1 Date of Disposition Place of Disposition
(address)
W
U) (se ion) {lot number) (grave number)
O Name of Sexton or Person in Charge of Premises
QV t'�Z�� ►-T�(J '
(please print) �/� ,�
IL
W Signature Title ci�>�/�F
DOH-1555 (10/89) p. 1 of 2 VS-61