Ferguson, DeElda SOWN OF QUEENs5BU�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (J /r /_GOx p(, I?Eiz�l
Name,V,o05�/-,,Z)/9 �i �f'� ��d�1 Case # d&l
Date of Cremation ! 11— acl-I'l
Time Cremation Started
Time Cremation Completed P P!M i
Type of Container <f' jq/t 09,o19RD 31?,P, z_- A -,67- QE ���_ZXf
Remarks
02 NI
l cz r J�`'/�l✓l i
/o'Z i"3 M
%/e
i
i
i
TORN 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:
, Net
np w 1 r1 "G Mary Fema 1 a
(Name) (Sex)
101 Lord Howe Street, Ticonderoga New York 12883
(Street ) (City) (State) (Zip Code)
who died on 7th day of July 19 2001
at Glens Falls Hospital, Glens Falls, New York
(Place) (Address)
Nave and address of nearest living relative or name of person
authorizing cremation:
Mary Lou Winters, 29 Lillie Lane, Putnam Station, '_New 'York 12861
(Name) (Address)
Relationship to the deceased niece
Name of Funeral Home Wilcox & Regan Funeral Home_,
IMPORTANT: t: :'.". r,,: .,-~: = -,T c
I e resent that to the best of my knowledge, ,;;the dEvld has or
har no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorizalti-en akp arrange
for the cremation of the remains and to dir:ect:: the:, O_i;,Spo-sition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agrees„to,,.proit ;t.,, defend
and save harmless Pine View Crematorium from any .an.d -all.:claims
and demands for loss or damages which may be made against thew 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.
AQ.Lt1 /►t11 tn C llQ�l!mfi 7.Lp'esx 46
(Witness) (AddresrN
(Si ature of Relative or Legal Rep. and Address)
Signed on this dates '7 , q 1 0 1 -
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
CreNatorium 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
direftfii;- 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.
Nasdstyxafoaw,or,-!plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered on
t + °uu� orization to cremate form before the remains will be
6 . Ualebs other arrangements are made the cremated remains will be
mt.�, led via Registered U.S. Mail within three days of cremation to
th3 funeral home handling the service. There will be a $20 . 00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $195. 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 .