Cote, Robert " a
TOWN OF QUEENSBURY
Pine Vtett, Cemetery and Cretuntonunt
21 Quaker Road, Queensbnry, NY. 12804-5902
(518) 745-4476 (518) 745.4477
http //wNv\v queensbury net
Funeral Director: I`1 . 13 1 r /m o r
Name of Deceased: Cc,4-.
Case Number:
Date of Cremation: a 4 u —
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Time Cremation Started:
Time Cremation Completed:
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T�)� OFQUEENSBURY
y "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:
pp
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on / '7 day of 20 i✓� Li
at
(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 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
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.
(WITN SS) DD ESS)
SIGNA RE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
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.
FEB-18-2005 10:50AM FROM-DENVER VITAL RECORDS +303 436 7509 T-868 P-001/001 F-748
` Permit No_ 18690.
-` AUTHORITY FOR FINAL DISPOSITION
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
cw•.u�Ds�nment
ur Public maaih
and fnV40nmem
READ CAREFULLY
It is unlawful for any person in charge of a burial place or crematory to permit burial or other disposition of a dead
human body or fetus until a final disposition permit has been issued.
A final disposition permit may be issued only upon registration of a death certificate.
A final disposition permit is required for any type of disposition of a dead human body or fetus.
This permit may be used for transporting by common carrier.
All permits must be endorsed by the sexton, recorded in the sexton's register, and forwarded within five days of
disposition to the local registrar or designee.
This final disposition permit,when completed and bearing the required signature,constitutes authority for burial, interment,
cremation,removal from the state, or other authorized disposition of the deceased named below, in accordance with Section
25-2-111 C.R,S. 1982. This permit must accompany the remains to their destination,
Name of Decedent Robert COTE Date of Death 02/17/2005 .
Sex M Age 75 DateofBirth 11./2511929 PlaceofDeatil Denver Denver
City County
Name of Funeral Establishment puckley Mortuary Services
Address of Funeral Establishment 3925 Newport Street, Denver, CO SC201
Type of Disposition Removal. from State Place lline View cemetery,Qucen.sbury,NY
Cemetery or Crematory City stave
I have examined the completed death certificate for the decedent named above,and authorize final disposition of the
remains. (To be signed by the office designated or established pursuant to Section 25-2-103 C.R.S. 1982 in the county
where the death occurred.)
Deputy
Sic�Rsture Title
605 Bannock St I?e-.iver, Co 80204 02118/2005
Address
Date •'
Items below are to be completed by the cemetery or crematory official.Where there is no full-time person in charge,the
funeral director may sign as sexton.This form must then be forwarded within five days of disposition to the local registrar or
designee.
Type of Disposition t^U", Date z- `1 U`.) In Lot /„Block Section
Place 0" ry tti C rcvn- ( `.'t r l4ti
f, Cameiery o.Crett�tpry City state
Signature
Title Date