Heermans, Alfred B. / / ,0 `� 7
Name
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Date of Cremation � '_ � _______ __--------------
/ r Time Cremation Started
Time Cremation
Type of container
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POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 365 days a year, 24 hours a day. Prearrangements by telephone for
acceptance of remains is necessary.
2. Pine Crematorium, Inc. is located on the grounds of the Regan & Denny Funeral Service, Inc., Quaker Rd., Town of
Queensbury - adjacent to Pine View Cemetery,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 Crematorium, Inc., 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.
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.
PRICES EFFECTIVE MAY 1, 1986
Cremation, Administration Costs and Recording Fee:
Adult ................ ...... ... .................. ..... ............ ............... $125.00
Children(age 13 months to 12 years) .................... .... ... ............. ....... 80.00
Infants(stillborn to 12 months) . ......... ................ ... ......... ............... 45.00
Shipping container, carton and packing fee for shipping and registered priority mail with return receipt included in the above prices.
ADDITIONAL SERVICE
Storage of cremated remains- per month ............................................ $ 2.00
V'
4IN71E PINE CREMATORIUM, INC.
Quaker Road, Glens Falls, NY 12801
CREMATORIUM,INC. Phone (518) 798-4726 or if no answer 792-1114
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine Crematorium, Inc. in accordance with and subject to its Rules and
Regulations to cremate the remains of:
Alfred B. Heermans Male
(NAME) (SEX)
695 Dixon Road Apt. 14, Queensbury, New York 12801
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 5th day of Feb. 19 88
at Glens Falls Hospi ta1 Glens Falls, New York
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Joan B. Heermans 695 Dixon Road Apt. 14 Queensbury, NY
(NAME) (ADDRESS)
Relationship to the deceased husband
Name of funeral home Regan and Denny Funeral Home
X 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 Crematorium, Inc. 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 orVfraudent.
(WITNESS) / (SIGNATURE OF RELATIVE OR LEGAL REP.)
82 Seminary St. Fort Edward, NY 12828 5 Dixon Rd. Apt. 14 Queensbury, NY 12801
(ADDRESS) (ADDRESS)
Signed on this date a-
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine Crematorium, Inc. to dispose of the cremated remains as follows:
Mail to return to Regan and Denny Funeral Home
Other arrangements- please specify:
If pulverization of cremated remains is requested, check here: 0