Koliada, Kenneth Funeral Director: C1 r
Name of Deceased: Ke h,eA K-115 d 5
Case Number: a3�
Date of Cremation:
Retort: T E.
Time Cremation Started: •- 15 A M .
Time Cremation Completed:
Type of Container:
Remarks:
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, OWN OF QUEENSBURY0.
PINt 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) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on C)\ day of 3 r 20
�
at " V ec ryx -y 6S
t (PLACE) (ADDRESS)
f Name and address of nearest living relative or name of person authorizing cremation:
Relationship`to deceased L �—N�
k
Name of Funeral Home M, n.F'(-(,s �GIYI
I
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.
(WITNESS) (ADDRESS)
(SIG TURE 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 t
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. 3:`O 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 sav
harmless Pine View Crematorium from any and all claims and demands for loss or dal ges
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.
STATE OF VERMCONT—ACIMLCYOFHUMANSERVICES—DEPARTMENTOFHEALTH No.
OIF.FI HE CHIEF MEDICAL EXAMINER
MEDICAL EXAMIl 1S PERMIT TO CREMATE A DEAD HUMAN BODY
Full name of decedent
Decedent's address Q',
Date of death J?7 3 2C�o� Town of death 1' -C
Cause of death certified by �1 1'�►�arl`V
Permission to cremate the body o�ecedent atr/y��(�
i
,p^ (Name and address of Crematory)
has been requested by C `�� �/"�E �' . / ( !� (L leef,;;<
(Name and address of Funeral Director representative or person re esting tt permit
Vermont Funeral Director License Number:
Being sufficiently informed as t i a c ances of the death of the above
described decedent,permissi n is an cr a body as requested.
Date, L (Signed) ,Medical Examiner
Address
're+ 18 VSA SEC.5201(b)
DISTRIBUTION:White Original:Crematory via Funeral Home or person requesting permit Yellow:Funeral Home Pink: Local M.E. Goldenrod:OCME
I
MEDICAL EXAMINER'S CREMATION PERMIT:PURPOSE AND PROCEDURE *0
As outlined in Vermont Statute Title 18,Section 5201,Medical Examiners To reach a Local Medical Examiner to sign a cremation permit:888-552-2952
(Chief,Deputy,Regional,and Assistant)must issue permits for bodies of
persons who die in Vermont and are to be cremated.The OCME will Points to Remember:
maintain a list of Medical Examiners that are authorized to perform this duty A$10.00 fee for reviewing death certificate and signing the permit is statutorily
for distribution to funeral directors and crematories.The list will be mandated and paid directly 7lte Medical Examiner by the funeral director or the
distributed a minimum of once per year to funeral directors,crematories and person requesting the permt
medical examiners,and updated as necessary.Only individuals appearing
on this list are authorized to issue cremation permits. All death certificate amendreAnts resulting from the cremation permit review
process will be issued by thmcw.
The purpose of having a medical examiner review a death certificate prior to
cremation is to ensure that questions about the certification of death are Cremation permits are nev .to be pre-signed.
addressed before irrevocable disposition of the remains occurs.Following
cremation,there is no way to examine a body.Therefore,the medical Cremation permits are nowp*in four-part format.The goldenrod copy is for
examiner must be satisfied that the cause and manner of death are correct the local Medical Examiner to retain.The pink copy is for the funeral director or
and that no further examination or judicial inquiry is warranted before a the person requesting the permit to retain.The yellow copy is mailed to the OCME.
cremation is authorized. The white original is to be filed at the crematory.
The funeral director or other party requesting the cremation permit is If there are any concerns or questions regarding the certification of death,
required to present a copy of the death certificate to the Medical Examiner. cremation will not be authorized until they are resolved.Any questions about
Medical Examiners are required to make personal inquiry into the cause and signing a cremation permit should be directed to the OCME.
manner of death.A review of an accurately completed death certificate may
be all that is necessary. OFFICE OF THE CHIEF MEDICAL EXAMINER
I I I Colchester Avenue,Baird 1
If the cause and/or manner of death as it appears on the death certificate are Burlington VT 05401
not accurate or not etiologically specific,the Medical Examiner must initiate Voice:(802)863-7320
an investigation prior to issuing the cremation permit. FAX:(802)863-7265
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