Frustaci, John a
4 TOWN OF QUEENSBURY
Pint View Cemetery nnrl Cretnn tort usit
21 Qunker Rond, Qtteenshttry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp liw\v\v queensbury net
Funeral Director:
Name of Deceased: H G-tt
Case Number: 3171
Date of Cremation: T — 0'5-
Retort.
Time Cremation Started: a JA 5 17
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Time Cremation Completed: e3 5 � 6
Type of Container: � �
Remarks: I
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r o it n)l ,1' nrurnl Btnitty ... A Cood P I n c e to Ltue
State of Vermont
Department of Health
Office of the Chief Medical Examiner No.
PERMIT TO CREMATE
1A DEAD HUMAN BODY
Full Name of Decedent Y hI) Pi U,4c1c i
Decedent's Address: ACDLa r 1 4- l I La LA---rl l31 V I M-D�
Date of Death:` ) ) 0:�-s I o'�—) Town of Death:
Cause of Death Certified by:
Permission to cremate the body of this decedent a PGe
(Name and Address of Crematory)
has been requested by//GyraFi C 11 , /0/n A,14/oL/LC,Z) J�,/'4 oT/O a��A�w�j � i7Fi/S�i4G��y/Z g 87
46W Yozl< (Funeral Director Name and Address)
Vannoat-Funeral Director License Number: D 'm
Being sufficiently informed as to the causes and circumstances of the death of the above described decedent,per-
mission is&rantSpd to cr mate the body as requested.
Date: ,Medical Examiner
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Addres . //
18 VSA SEC.5201(b) White Copy:Funeral Director Yellow Copy:OCME Pink Copy:AME/RME I
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Town of-CQueensbury
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 subject to its Rules and Regulations to
cremate the remains of:
(Name) (sex) n
(Street) (City) (State) (Zip Code)
who died on <5 TN day of ��fo-%�e�?R fi/? 20
LA
(Place) (Address)
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Name and address of nearest living relative or name of person authorizing cremation: ''.J`
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(Name) (Addy )
Relationship to the deceased
Name of Funeral Home Ih e u (},EL C - ,i/J61D&1L&U
IMPORTANT: ins910��
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator Or�r�rpWj aptifMld
device in his or her body. (Circle One) '2r!0'7Elt" mo
,aniff lei?u8
I certify that I have full power and authorization to arrange for the cremation of the remains and tovluqr Cfttl—
cremated remains,that any persona{possessions have either been removed or may be delm Md
save harmless Pine View Crematorium from any and all claims and demands for loss or da *pow tttsm
by reason of or connected with the cremation of said remains as directed,whether such Bairns 0� i1r AOt tAltipily
groundless,false or fraudulent_
(Address) t;f &ws) rusibMO
ignature and Address of Relative or Legal Representative)
Signed on this date: {v/ Do- j
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: /� i C k 44 1)
If pulverization of cremated remains is requested,check here
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Revision:July 7,2004
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Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine Views Cemetery. The
crematorium operates Monday through Friday from 7:00am to 3-.30pm. Prior telephone
arrangements fof the acceptance of remains are necessary. Prearrangements are
necessary for Saturday cremations.
2. A "Authorization for Crernation"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 regutar 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. Cardiee pacemakers, defibrillators or other battery operated devices must be removed
bek"any remains will be accepted.
` I , ,v-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
NOO Registered U. S. Mail within three days of cremation to the funeral home
anus^/"Ot*.iESWS=, vice
na,r� r unless other arrangements are made. There will be a 25. charge
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6. Crremadmt,Administration Costs and Recording Fees:
Aduk _ $300.00
Children (ale 13 months to 12 years) $150.00
lnfents (sditom to 12 months) $100.00
Qvsrdme Cremations(Weekdays) $400.00
sekgft Cis $400.00