Krummenacker, Raymond r
TO'74N OF QUEEVBU-WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director LdaE/V/Y
Name / NIM6 MWA� &AC& Case # \10
Date of Cremation
Time Cremation Started ��T MA
Time f
Time Cremation Completed
Type of Container
Remarks :
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DISPOSITION OF CREMATED RFMnINS
I hereby direct Pine View Crematorium 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 week
7 :00 R. 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
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 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-P'4
on the authorization to cremate form before the remains will bp
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Register-ed U.S- Mail within three days of cremat lorr
to the funeral home handling the service. There will be a $20. 00
charge for thrs service.
Cremation, Adm ,nrstr-an on Costs and Recording Fee : Adult $ 175. 0r
Children (age 13 months to 12 years ) t100. 00 Infants ( stillborn
to 12 months ) $60. 00
TOWN OF QUEENSRURY PINE VIEW CEMETERY �y
R
CREMATORIUM
Uuaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUT)ion IzATION TO CREMATE
THe undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the'' ��""r''"emains of :
Rand Fr_ede�'�r_UMwenacker Halo
(Name) (Sex)
10 ColuwbiC-Ave• H-raam 12802
(Street ) (City) (State) ( Zip Code )
who died on t3th day ofSeptembei 19____95
at 10 Columbine Ave . , South Glens Falls NY
(Place) (Address)
Name arid address of nearest living relative or name- of person
authorizing cremation :
Daniel -
(Name ) (Address)
Relationship to the deceased son-in-law
Name of Funeral H o m eCarleton Funeral Home 7 np
IMPURTANT:
I repre a to the best of my knowledge, the deceased has or
I►a o pl<e►- ' n his or her body. (Circle One)
1 certi -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.
Mitnes ) (Address)
(
(signature of R6 lative or Legal Rep. and Address)
Signed on this date :