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Name _y /� 1 "��iJ/ ase Humber
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of containers
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TOWN OF RUEENSBURY _
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12801
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
(Name) (Sex)
/�6'W0?
(Street) (City) (State))' (Zip Code)
who died on day of 19,&
at All
(Place) (Address)
Name ante/d'� address of nearest living relative or name of person authorizing cremation::
(Name) // (Address)
Relationship to the deceased
Name of funeral home ,�,pfsr�c�p �Gsi^er/ /�iy; .riY� �i�/�C �L�Z���✓� ^��
IMPORTANT:
I represent that to the best of my knowledge,the deceased has or as n 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) Signature of Re tive or Legal Rep.)
Z" ,e,��
(Address) /� J/� (Address)
Signed on this date
DISPOSITION OF CREMATED REMAINS -
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangement - please specify:
If pulverization of cremated 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.
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.
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
BREWER FUNERAL HOME,INC.
Corner of Lake Ave.6 Church St. •
LAKE LUZERNE,NEW YORK 12846
Phone(518)696-27"
CRAIG A.REUKAUF.Pres.Lic.Mgr.
CUSTOMER'S DESIGNATION OF INTENTIONS
FOR DISPOSITION OF CREMATED REMAINS
Full name of deceased
IPleese PRINT Namel •�-- �j
SCHEDULED PLACE OF CREMATION SCHEDULED DATE OfrCREMATION
The undersigned person(s)making arrangements request the Disposition of Cremains as indicated below:
( J Interment or Inurnment
PLACE OF INTERMENT OR INURNMENT
( � ] Release to: -s�'G/�
SPECIFIC NAME
[ ] Ship to:
SPECIFIC NAME
STREETADDRESS CITY a STATE
ZIP CODE
[ ] Other:
I(we)hereby represent that I am(we are)of the same of nearest degree of relationship to the deceased and/or are legally authorized or charged with the
responsibility for the final disposition of his/her body,and that the above are my(our)instructions for the disposition of the cremated remains of the
above named deceased.I(We)state that I(We)understand that the cremains of the above named deceased may be disposed of in any lawful manner by
the above named funeral home,if said cremains are unclaimed after 120 days from the date of cremation.
Dated this 46� day of �L/G , 1 g �o
�/ ,(� MR.
��_S/gL/E � �T�� MRS.
MISS
P Air i 7k
Address
Address
City and State Zip Code City and State' Zip Code
Phone Number Phone Number
The ndersigned Funeral Director attests to the following:
(1) If the cremated remains of the above named deceased are unclaimed after 120 days from the date of cremation, id cremains will be disposed of
in the following manner 45e,Y0,1i 4'7- —
(2) A copy of the foregoing Designation of Intentions was given this 61, YIV— day of wU&X 19 UP
to the person(s ho made arrangements fo re ation.
Signature of Funeral director Making Arrangments Printed or Typed Name of Funeral Director
The funeral firm's copy of this Designation of Intentions will hereafter be completed to show the following:
Actual Cratifof Cremation Name of Crematory
Address
City and StatSoor Zip Code
Data of Disposition of Cremains Location of Disposition of Cramains
Manner of Disposition of Cremains:
Da
t this day of 19
Signature o arson Making Disposition of Cremains Printed or Typed Name of Person Making Disposition of Cremains