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Bissell, John a- rrnl+N OF UEEVBU-'�Y JPINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director l Name !/ g15s�.`�L Case # Date of Cremation�v�� �� Time Cremation Started�q-L-�Y -Z 4I M ' Time Cremation Completed & M ' Type of ContainerC191??Jgodg-D g-lyJ' L41b cf� -rff�,�f Remarks : fj/I H ztm / li 11 ©O �d /M DISPOSITION OF CREMATED REMnINS I hereby direct Pine View Cremaltorium to dispose of the cremated remains as follows : Mail to Other arrangements - please If pulverization of cremate remains is requested, check here __._ POLICIES, RULES nND REGULATIONS 1 . The crematorium will be open for cremations 5 days a wept( 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 t� 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 direcF 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 styrafoam or plastic containers will be accepted. 5. The question relative to cardiac_ pacemakers must be answer- 1 on the authorization to cremate form before the remains will tp 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 t20. 00 charge for this service. Cremation, Administration Costs and Recording Fee : Adult t175. 1ro Children (age 13 months to 12 years ) $ 100. 00 Infants ( stillborn to 12 months ) $60. 00 3 TOWN OF OUEENSBURY PINE VIEW CEMETERY A CREMATORIUM Ouaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accardance with and subject to its Rules and Regulations to cremate the remains of : John M. Bissell male -----04 am e )---- (sex) _ 38 _Scho_o_1_, St . , Hudson Falls NY 12839 - (Street ) (City) (State ) ( Zip Code ) 6th day of September lq 95 who died on Y at 38 School St . , Hudson Falls , NY 12839 (Place) (Address) Name and address of nearest living relative or namm of person authorizing cremation : Stacy Bissell 18 Garner St . , Glens Falls , NY -------- (Name) (Address) Relationship to the deceased d^LghtPr Name of Funeral Home Carleton Funeral Homo - 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 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 grG-641dI ss� ,, fa se or fraudulent. Carleton Funeral Home , Inc . itr s ) (Address) f Glens Falls , NY 12801 (Signature of Relative or Legal Rep. and Address ) Signed on this date : Sept . 7 , 1995