Smith, Mary Jane 70UN of QUEEVBU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Direct or /C (1U�-/?
Name MARY Case # dC�y
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container ``�ARD P10" e45%
Remarks :
a z
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 cremate 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 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 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 $185. 00
Children (age 13 months to 12 years) $11,0. 00 Infants ( stil"lborn
to 12 months) $70. 00
TOWN OF OUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker 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
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Mary Jane Smith Female
(Name) (Sex)
RR, Upper Road , Poultney, Vermont 05764
(Street ) (City) (State) (Zip Code)
who died on 2nd day of November 19 95
at Her Residence ,
RR, Upper Road Poultney, Vermont 05764
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mr. Andrew Smith
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Roberts-Aubin Funeral Hama
IMPORTANT:
I represent at 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)
(Signature of Relative or Legal Rep. and Address)
Signed on this date : November 3 , 1995
�NOV —'- 3 - 95 FR I 1 2 : 5 1 JEC LASERS, I NC J P 0 :2
TuaN OF (XJFPW;0U9Y
i)IW VYg!W C414UTC':HY
K
CKMATORIUM
Qµ,&Hgr• Road, Qupvnsoveyj New York 1�8�f4
phone t31d1 Cremator•lum 745--4471 ar• if no A111 t"
CTM"Lolly 741, -4476
AUTHdRI ZAT ION TO C:ACMATF.
The undrrsagnrcl requests and authorirar Pinv View CreMatO► i0m% in
aCCOrdance with and Subject to its Rule* and Regulabldnr to
eramate the romans aft
Mary Jal'ia Smith _ Femaai*
-- (Sam)
(Name)
RR , up��r. .Q .._..r.N°�ndy, Vermont _,..,.. =....,.�..-
t Crret ) (City) (St Ott tZID Code)
y November__-_ 19 45
nd
who died O n ,- ,_.�..�. 1 .,..... __.._d A a�' ...---
Vermynt 05754
--
at Her Reairlcay� _ _Rnc..,UL, ...1�.OA19.r.
...,..•.(Pl(Place) (Address)
Name and addre()s of mQ41-est 13ving r'I , ative Or A#%# Of person
Autharixlnpf'easAt �ans
M1 • Alldrew Smith "-
—i�(Na me (Address)
Relationship to the deceasad ..,..... �.: �r...,, .., ..,,... - �......_....- ..,...
Name of Funeral
1MPURIANT s
l represent to the t)tet of my knowlodpes the tivdrased hat Or
�a n'p" pa oAtMktlr 1h his or her body. (t~Irt:le drte)
1 Certify thot I h#Ye the full power and authoritlitlOn to oeroMp
for the dr4oaetion of thf e0MAins and to direot the diapOlItaan Of
tfty crtosted rvmatnst thou +ny pvrsonal possessions have wither
been romaved or may be dtt6tr9yo0t and agrft %o pratect, defend
and S&Yl harMltss Pin* Vrvw Cremotorium from any and all Cleims
anp afoonds for loss or d,smaget+ which may be madtt a9sinst them by
redison of or connar.tad with tht Cromntlon of sold remains is
01rectedt whether such claims Pr demands art or art not wholly
gr^qundles61 fAIse oto fraudulent.
t� nature o elAtive or Legal Rep. and Addrtss)
s f pnov on th t s date ) _ November 3 , 1995T-.—